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UNIVERSITY  of  CALIFORira 
AT 
LOS  ANGELES 
UBRARY 


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,-  0CT28 


2921 


li'i'  '■ 


PRACTICAL  DIETETICS 


IVITH  SPECIAL  REFERENCE  TO 
DIET  IN  DISEASE 


BY 

W.  OILMAN  THOMPSON,  M.  D. 

PROFESSOR    OF    MEDICINE    IN    THE    CORNELL    UNIVERSITY    MEDICAL    COLLEGE, 

NEW    YORK 

VISITING    PHYSICIAN    TO   THE    PRESBYTERIAN    AND    BELLEVUE    HOSPITALS 


0711 


"  Good  diet  with  wisdom  best  comforteth  men  " 

TUSSER   (1520) 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1900 

I0TI\ 


Copyright,  1895, 
By  D.  APPLETON  AND  COMPANY. 


T  5^ 


? 


INTRODUCTION. 


The  subject  of  the  dietetic  treatment  of  disease  has  not  received 
the  attention  in  medical  literature  which  it  deserves,  and  it  is  to 
be  regretted  that  in  the  curriculum  of  medical  colleges  it  is  either 
wholly  neglected  or  is  disposed  of  in  one  or  two  brief  lectures  at  the 
end  of  a  course  in  general  therapeutics.  Upon  examining  the  stand- 
ard treatises  upon  the  Theory  and  Practice  of  Medicine,  as  well  as 
monographs  upon  important  diseases,  such  as  those  of  the  circula- 
tion, nervous  system,  and  skin,  one  cannot  fail  to  be  impressed  with 
the  meagre  notice  given  to  the  necessity  of  feeding  patients  prop- 
erly, and  the  subject  is  usually  dismissed  with  such  brief  and  in- 
definite phrases  as  "The  value  of  nutritious  diet  requires  mere 
mention,"  "  A  proper  but  restricted  diet  is  recommended,"  and 
favourite,  if  not  convincing,  expressions  are,  "  The  patient  should 
be  carefully  fed,"  and  "  General  dietetic  treatment  is  of  primary  im- 
portance." With  such  vague  directions  the  dieting  must  indeed  be 
very  "general." 

In  many  excellent  works  upon  food  and  dietetics  the  space  de- 
voted to  the  practical  application  of  dietetics  to  disease  is  compara- 
tively insignificant,  and  much  less  emphasis  is  given  to  this  matter 
in  hospitals  and  in  the  training  of  nurses  than  is  demanded  in  the 
interests  of  medical  science. 

A  writer  of  wide  experience  in  practical  dietetics,  Mrs.  E.  H. 
Richards,  says :  "  At  present  there  are  comparatively  few  persons 
who  are  called  upon  to  feed  the  sick  to  whom  a  glass  of  milk  or  a 
pound  of  beef  represent  any  definite  amount  of  food  materials.  Still 
fewer  who  can  tell  how  much  food  value  a  glass  of  lemon  jelly  or 
wine  whey  represents,  and  yet  the  adult  patient  is  dependent  upon 
the  attendant  even  more  than  the  week-old  infant  for  the  requisite 
nutrition." 

The  present  volume  has  been  prepared  with  the  view  of  in  some 


iv  INTRODUCTION. 

measure  making  good  these  deficiencies  by  furnishing  a  text-book 
in  which  the  practitioner  of  medicine  may  find  detailed  the  appro- 
priate diet  for  each  disease  which  is  at  all  influenced  by  right 
feeding. 

Quite  as  much  depends  upon  the  suitable  preparation  of  food  as 
upon  the  selection  and  limitation  of  the  food  itself,  and  it  has  there- 
fore been  thought  advisable  to  include  a  general  account  of  the 
composition  and  uses  of  foods,  and  the  changes  which  may  be  pro- 
duced in  them  by  cooking  and  other  processes.  In  this  first  portion 
of  the  work,  however,  the  practical  application  of  such  knowledge  to 
the  feeding  of  the  sick  has  been  constantly  emphasised  rather  than 
unnecessary  scientific  detail. 

The  reader  will  also  find  a  discussion  of  representative  hospital 
dietaries,  the  official  dietaries  of  Government  institutions,  and  sec- 
tions upon  the  proper  feeding  of  infants  and  children.  Numerous 
cross  references  and  a  complete  index  have  been  added  to  avoid  un- 
due repetition. 

Bennett  wrote,  as  long  ago  as  1858:  "Of  all  the  means  of  cure 
at  our  disposal,  attention  to  the  quantity  and  quality  of  the  ingesta 
is  by  far  the  most  powerful."  While  fully  concurring  in  this  view, 
that  appropriate  dieting  is  often  more  needed  than  medication,  I 
distinctly  disclaim  the  advocacy  of  any  special  dietetic  system  as  a 
cure-all,  as  well  as  the  specific  influence  of  any  one  food  in  the  gen- 
eral treatment  of  disease.  It  cannot  be  expected  that  the  experience 
of  a  single  individual  should  cover  so  extensive  a  ground  as  that 
which  embraces  the  uses  or  application  of  all  foods,  and  I  have 
therefore  impartially  introduced  the  views  of  others,  especially 
where,  as  in  such  diseases  as  gout,  diabetes,  and  obesity,  opposing 
dietetic  theories  are  held  by  clinicians  of  extensive  experience  and 
authority.  Due  acknowledgment  of  these  references  is  made  in  the 
text,  but  the  admirable  researches  upon  foods  of  our  own  Govern- 
ment, found  in  the  published  reports  of  the  Bureau  of  Agriculture 
and  of  the  Commission  to  the  Paris  Universal  Exposition  of  1889, 
and  at  the  Columbian  Exposition  of  1893,  are  especially  to  be  com- 

W.  Oilman  Thompson. 

May  a8,  tSgS- 


CONTENTS 


Introduction 


PART   I. 

FOODS   AND   FOOD   PREPARATIONS. 

Elementary  composition  of  foods I 

Food  classification  .............  4 

Force  production.     Energy  from  food 7 

Force-producing  value  of  the  different  classes  of  foods 15 

I.  Water 15 

II.  Salts 16 

III.  Proteids,  carbohydrates,  and  fats 16 

Stimulating  foods 18 

Economic  value  of  foods 19 

Nutrition          ..............  22 

Animal  and  vegetable  foods  compared         .        .        . '      .        .         .        .        .22 

Vegetarianism 28 

The  classes  of  foods        .        .        .        .        , 30 

I.  Water 30 

Uses  of  water  in  the  body 31 

Purity  of  water 31 

Varieties  of  drinking  water       ..........  32 

Hard  and  soft  water 32 

Rain  water 32 

River  water  .............  33 

Distilled  water      ............  33 

Filtered  water 33 

Boiled  water 33 

Special  dietetic  uses  of  water 34 

Excess  of  water 34 

Deprivation  of  water.     Water  starvation 35 

Thirst 36 

Temperature  of  drinking  water 37 

II.  Salts 37 

Varieties  of  salts 37 

Uses  of  salts  in  foods 38 

Excess  of  salt 38 

Deprivation  of  salt 38 

Sodium  salts 39 

Potassium  salts 40 

Calcium  salts 40 

V 


yi  CONTENTS. 

PAGE 

Phosphorus 40 

Sulphur 41 

Iron 41 

Vegetable  acids -4^ 

III.  Animal  foods. 

Milk 41 

Exclusive  milk  diet 42 

"  Milk  cure " 44 

Chemical  composition  of  milk 44 

Fat 45 

Lactose 45 

Casein  and  albumin 45 

Varieties  of  milk 46 

Cow's  milk         .         .         .         .         .         .         .         .         .         .         .         .46 

Human  milk 46 

Drugs  in  human  milk 48 

Goat's  milk .         .49 

Ass's  milk 49 

Mare's  milk       .        .        .        .      • .49 

Milk  analysis 49 

Reaction,  colour,  taste,  odour    .         . 49 

Estimation  of  solids 49 

Estimation  of  fat 50 

Estimation  of  lactose .         -SO 

Estimation  of  albuminoids 50 

Milk  adulteration  and  impurities 51 

Addition  of  water .         .         •52 

Addition  of  colouring  matter 52 

Addition  of  preservatives 53 

Addition  of  thickening  substances 53 

Milk  contamination  by  the  cow's  food  ........  53 

Contamination  by  the  cow's  condition .53 

Contamination  by  the  cow's  disease  germs 54 

Contamination  by  extraneous  disease  germs     .        .        .        .         .        -55 

Souring  and  decomposition v.  •  56 

Absorption  of  bad  odours 57 

Prophylaxis  against  milk  infection 57 

Uses  of  milk 58 

Milk  digestion 60 

Normal  (Rennin) 60 

Abnormal 61 

Adaptation  of  milk  for  the  sick 62 

Methods  of  altering  the  taste  of  milk 63 

Methods  of  improving  the  digestibility  of  milk 64 

Skimming 64 

Boiling 64 

Dilution  with  water 65 

Dilution  with  alkaline  and  aerated  waters 65 

Dilution  with  amylaceous  foods 66 

Addition  of  alkalies,  acid,  and  other  substances 66 

Methods  of  predigestion  of  milk 67 

Peptonised  milk 67 


CONTENTS.  vii 

PAGB 

Pancreatinised  milk         .        .        . 68 

Koumiss .............  69 

"  Koumiss  cure  "...........  71 

Kefir 72 

Matzoon 73 

Methods  of  sterilisation  and  preservation  of  milk        .....  73 

Sterilised  milk          ...........  73 

Pasteurised  milk      ...........  75 

"  Humanised  milk "          ..........  77 

Modified  milk.     Milk  laboratories 78 

Milk  derivatives ............  81 

Condensed  milk 81 

Cream 82 

Butter 84 

Buttermilk 85 

Cheese 86 

Whey 88 

Eggs 89 

Raw  eggs.     Eggnog.     Egg  albumin 90 

The  cooking  of  eggs    ...........  90 

Preservation  of  eggs 92 

Meats 92 

Consumption  of  meat 92 

Composition  of  meats  ...........  93 

Raw  meats . 94 

Digestibility  of  meats ...........  95 

Beef 96 

Beef  preparations  for  the  sick 96 

Solid  meat  preparations  ..........  97 

Scraped  meat 97 

Beef  meal 98 

Beef  jelly 98 

Beef  extracts 98 

Beef  blood 99 

Beef  peptonoids -99 

Fluid  meat  preparations. 

Beef  juice 100 

Beef  tea loi 

Bouillon       ............  102 

Beef  broth 103 

Beef  extracts         ...........  103 

Summary 104 

Various  meats 105 

Beef  tongue 105 

Veal 105 

Mutton 105 

Lamb ■      .  106 

Venison 106 

Pork 106 

Ham  and  Bacon 106 

Fowl 107 

Came , 107 


Viii  CONTENTS. 

PAGE 

Animal  viscera 107 

Sweetbread     .............  107 

Tripe,  liver,  kidneys,  brains,  blood 108 

Isinglass,  gelatin         . .         .         .         .108 

Jellies     ..............  109 

Fish ■ no 

Crustaceans     .............  112 

Shellfish — oysters,  clams,  mussels .        ,        .112 

Vegetable  foods ,         .         .         .         .113 

Sugars 113 

Sugars  and  the  urine 114 

Cane  sugar,  saccharose 114 

Caramel 115 

Molasses  and  treacle 116 

Grape  sugar,  glucose .116 

Milk  sugar,  lactose      . 117 

Mannite  and  levulose 117 

Honey 117 

Saccharin 117 

Cereals  and  other  starchy  foods 1 18 

Starchy  foods  in  general 118 

Bread  making. 

Structure  of  the  wheat  kernel l2o 

Bran 120 

Gluten .  121 

Composition  of  bread       .         .         .         .         .         .         .         .         .         .121 

Bread  baking .  121 

Development  of  carbonic-acid  gas   ........  121 

Yeast,  leaven 122 

Baking  powders 123 

Aerated  bread 124 

Varieties  of  bread  stuffs 125 

Wheaten  flour  and  bread 126 

Whole-meal  bread  ...........  127 

Gluten  bread 128 

Rye  bread 120 

Biscuits,  pastry,  puddings,  etc.         .         .         .         .         .         .         .         .  129 

Prepared  farinaceous  foods "      .         .         .  130 


Buckwheat 


135 


Rye 136 

Com 136 


Rice 


137 


Barley 138 

Oatmeal 139 


Arrowroot 


140 


Tapioca,  cassava 140 

Sago 141 


Iceland  moss 


141 


Starchy  foods  for  children ,  141 

Diastase,  malt  extracts,  etc.         . 142 

Vegetable  food 143 

Legumes,  peas,  beans,  lentils 145 


CONTENTS.  ix 

PAGE 

Roots  and  tubers 147 

Potatoes 147 

Beets 149 

Succulent  tubers 150 

Green  vegetables 151 

Cabbages,  etc. 151 

Tomatoes,  etc. 153 

Fruits 156 

Composition  of  fruits  ...........  156 

Uses  and  properties  of  fruits 158 

Fruit  ripening.         .         .         .         .         .         .         .         .         .         .         .159 

Fruit  poisoning 159 

When  to  eat  fruit     .....                 ......  159 

Fruit  soups 160 

Dried  fruits 160 

Digestibility  of  fruits 160 

Varieties  of  fruits 161 

Lemons,  limes,  shaddocks 161 

Oranges  H 162 

Apples 162 

Pears,  peaches,  etc.          ..........  163 

Bananas  ........  163 

Banana  flour  for  invalids  .         .         .         .         .         .         .         .         .164 

Grapes     .............  166 

Plums,  prunes.         ...........  167 

Berries,  strawberries,  etc 168 

Melons    .............  169 

Figs  and  dates 169 

Fungi 169 

Poisonous  fungi  ............  171 

Lichen 171 

Nuts 171 

Fats  and  oils 172 

Uses  of  fats 173 

Digestibility  of  fats         .        .        . 174 

Animal  fats 176 

Bone  marrow  .............  177 

Vegetable  fats  and  oils 178 

Olive  oil 178 

Dietetic  uses  of  fats  and  oils 179 

Diseases  in  which  fats  are  beneficial 179 

Diseases  in  which  fats  are  forbidden 179 

Glycerin 180 

Cod-liver  oil 180 

Chemical  and  physical  properties 180 

Dosage 181 

Methods  of  administration 182 

Substitutes 184 

Uses    ...                184 


X  CONTENTS. 

PART   II. 

STIMULANTS,   BEVERAGES,   CONDIMENTS.  p^^^ 

Stimulants  and  beverages — uses 187 

Alkaline  and  mineral  waters,  efTervescing  waters 188 

Tannin 191 

Tea 192 

Physiological  and  therapeutic  action  of  tea        . 193 

Adulteration  of  tea     .         .         .         .        > 196 

Coffee 196 

Physiological  action  of  coffee .        .        .        .  198 

Adulteration  of  coffee 200 

Relative  value  of  coffee  and  tea 201 

Cocoa 201 

Cacao  butter 202 

Chocolate 204 

Kola 205 

Alcohol 205 

General  discussion  of  the  value  of  alcohol 206 

Physiological  action 208 

I.  As  a  food 209 

II.  As  a  stimulant 209 

III.  Action  upon  the  muscles         . 210 

IV.  Action  upon  the  temperature 210 

V.  Action  as  a  diuretic 211 

VI.  Action  on  mucous  membranes 211 

VII.  Action  upon  gastric  digestion 211 

VIII.  Alcohol  absorption 212 

IX.  Alcohol  elimination 213 

X.  Alcohol  poisoning 213 

XI.  Alcohol  and  climate 213 

Clinical  uses  of  alcohol 214 

I.  As  a  tonic 214 

2. .  As  a  vascular  and  cardiac  stimulant 214 

3.  Use  in  nervous  diseases .         .         .         .215 

4.  Use  in  fevers 216 

Proper  time  for  giving  alcohol    .         .         . .217 

Selection  of  proper  alcoholic  beverage 218 

Malt  liquors 219 

Beer 219 

Beer  brewing .  220 

Ale 220 

Porter,  stout       . 221 

Wine 221 

Composition       .............  221 

General  properties      ............  222 

White  wines .  223 

Red  wines 223 

Varieties  of  wines 224 

I.  Strong  dry  wines         .         .         .         .         .         .         .         .         .         .         .  224 

II.  Strong  sweet  wines 225 

III.  Aromatic  wines 226 


CONTENTS.  xi 

/ 

PAGE 

IV.  Acid  wines 226 

V.  Sparkling  wines 226 

VI.  "  Perfect "  wines 227 

VII.  Rough  wines 229 

Liquors 229 

Brandy,  whisky,  gin,  rum 230 

Therapeutic  uses  of  liquors 231 

Adulteration  of  liquors  and  wines      .........  231 

Liqueurs         ..............  232 

Cider 232 

Condiments  and  spices  . 233 

Properties,  uses,  harmful  effects 233 

Varieties 234 

PART   III. 

COOKING.      FOOD    PREPARATION  AND   PRESERVATION.      THE   QUANTITY   OF   FOOD 

REQUIRED. 

Cooking 238 

Object  of  cooking  food 238 

Varieties  of  cooking   ............  239 

1.  Boiling 240 

2.  Stewing 242 

3.  Roasting     .............  243 

4.  Grilling 243 

5.  Frying 246 

6.  Braising 247 

7.  Baking 247 

8.  Steaming 247 

Soups 248 

Cooking  of  fish 248 

Cooking  of  vegetables 248 

Food  concentration, — Condensed  food  .........  249 

Drying,  desiccation,  extracts 249 

Diet  of  concentrated  foods     .        .        .         .        .        .         .        ,        .        .        .251 

Food  preservation 253 

I.  Drying 253 

II.  Smoking      .............  254 

III.  Salting 254 

IV.  Freezing 255 

V.  Refrigeration 256 

VI.  Sterilisation         ,        .        .        .         .         ,..,.,.  256 

VII.  Exclusion  of  air. — Canning 257 

VIII.  Antiseptic  and  preservative  substances 259 

Substitutes  for  food 260 

Quantity  of  food  required      ,.......,,,  261 

Starvation  and  inanition 274 

Voluntary  fasting 275 

Symptoms  of  starvation 277 

Treatment  after  starvation 281 

Famine       .,......,.,,,,  281 

Improperly  balanced  ingredients  of  diet 281 


Xii  CONTENTS. 


PART   IV. 


FOODS  REQUIRED   FOR  SPECIAL  CONDITIONS. 


PAGE 


Age  and  food 283 

Food  in  childhood .        .        .        .  283 

Food  in  adult  life 284 

Food  in  old  age .        .        .        .        .        . 285 

Individual  size  and  food 289 

Body  weight  and  food 289 

Sex  and  food 290 

Diet  and  heredity 291 

Diet  and  race 291 

Climate  and  season  and  food 296 

PART   V. 

FOOD   DIGESTION. — CONDITIONS   WHICH   ESPECIALLY  AFFECT  DIGESTION. 

Hours  for  meals  and  order  of  taking  food 299 

Appetite 303 

Abnormal  cravings 304 

Variety  in  diet 305 

The  nervous  system  and  digestion .  307 

Circulation  and  digestion 308 

Temperature  and  digestion 308 

Exercise  and  digestion 312 

Rest  and  sleep  and  digestion 313 

Sleep  in  relation  to  meals 314 

Mental  emotion  and  digestion .316 

Food  in  the  mouth 316 

Food  in  the  stomach 317 

Quantity  of  gastric  juice 318 

Secretion  of  the  gastric  juice       .     '   .         .         . 319 

Hydrochloric  acid 320 

Pepsin,  albumoses,  peptones 321 

Peristalsis 322 

Duration  of  gastric  digestion  of  different  foods 322 

Digestion  of  proteids  in  the  stomach 325 

Abnormalities  of  gastric  digestion 326 

Hypersecretion 326 

Hyperacidity 326 

Absence  of  hydrochloric  acid 326 

Pyrosis 326 

Food  in  the  intestine .  326 

Pancreatic  juice 327 

Bile 327 

Digestion  of  fats 328 

Intestinal  gases 329 

Artificial  digestion 329 

Predigestion  of  starches 330 

Predigestion  of  proteids     .         .         .         .         .......  331 

Food  absorption .      •  .  334 

Elimination  of  food  waste 335 


CONTENTS.  xiii 

PAGE 

The  urine  and  food 336 

Tobacco  and  food 337 

Food  equivalents 337 

PART    VI. 

THE   GENERAL   RELATION   OF   FOOD   TO    SPECIAL   DISEASES. — DISEASES   WHICH 
ARE    CAUSED    BY    DIETETIC    ERRORS. 

The  general  relations  of  food  to  special  diseases  .......  339 

Diseases  caused  by  dietetic  errors.         .........  341 

I.  Insufficient  food 342 

II.  Overeating  and  overdrinking        .         .         .         .         .         .         .         .         .  342 

III.  Food  in  itself  wholesome,  but  which  is  injurious  because  the  ingredients 

are  not  properly  balanced 344 

IV.  Food  containing  parasites  or  their  embryos 344 

Intestinal  worms     ............  345 

Trichiniasis 346 

V.  Food  containing  ptomaines  . 350 

Poisoning  by  meat  or  game    . 351 

Poisoning  by  milk,  cream,  ice  cream,  and  cheese   ......  353 

Poisoning  by  shellfish  and  fish 353 

VI.  Food  containing  other  poisons  than  ptomaines   .         .         .         .         .         .  354 

Grain  poisoning      ............  355 

Ergotism 355 

Lathyrism   . 355 

Pellagra 356 

VII.  Food  adulteration      ...........  356 

Pigments 357 

Salicylic  acid 358 

Tin  and  lead  poisoning  ...........  358 

VIII.  Food  containing  micro-organisms    ........  360 

Milk  infection 360 

Tubercular  infection  through  milk  and  meat 360 

Typhoid  and  cholera  infection 361 

Infection  through  oysters 362 

Diphtheria  and  scarlatina       ..........  363 

Foot-and-mouth  disease          ..........  363 

Food  infection  through  flies 363 

IX.  Idiosyncrasies  in  regard  to  food.        ........  364 

X.  Alcohol  poisoning.     Alcoholism  .........  364 

Delirium  tremens 367 

PART   VII. 

ADMINISTRATION   OF   FOOD    FOR   THE   SICK. 

Methods  of  feeding  the  sick 369 

General  rules      .............  369 

The  appetite 369 

Regularity  in  feeding      ...........  370 

Quantity  of  food     ..." 370 

Details  of  serving  food 370 

Feeding  helpless  patients 372 


Xiv  CONTENTS. 

PAGE 

Sleep  and  feeding 373 

Cleansing  the  mouth       . 373 

Disinfection  of  utensils 374 

Feeding  unconscious  patients 374 

Nutrient  enemata 375 

Conditions  necessitating  rectal  feeding  .         . 375 

Hunger  and  thirst  during  rectal  feeding 376 

Method  of  injection 377 

Aids  to  retention 378 

Temperature  of  injections       ..........  378 

Number  of  injections 378 

Care  of  the  rectum 379 

Opium  in  enemata  ............  379 

Substances  available  for  rectal  feeding 3S0 

Prescriptions  for  food  enemata       .........  382 

Food  suppositories ,         .         .  382 

Inunction  foods ,         .         .         .         .  382 

Intravascular  feeding 383 

Hypodermic  feeding  ............  383 

Medicines  and  food ,         .         .  383 

Diet-kitchen  outfit 386 

Trained  purveyors  of  food 386 

PART   VIII. 

DIET   IN   DISEASE. — DIET   IN   INFECTIOUS   DISEASES. 

Diet  in  fever  in  general 387 

Pathological  physiology  of  fever .  387 

Dietetic  treatment 389 

Beverages  in  fevers 392 

Alcohol  as  a  food  in  fevers 393 

Diet  in  convalescence  from  fevers      .........  395 

Typhoid  fever 397 

Pathological  physiology 397 

Dietetic  treatment 398 

Milk  diet 398 

Substitutes  for  milk  diet 400 

Thirst 402 

Alcohol 403 

Relation  of  intestinal  antisepsis  to  diet 404 

Care  of  the  mouth 405 

Convalescence 406 

Rules  for  feeding  atypical  cases 408 

Typhoid  fever  in  children 409 

Typhus  fever 410 

Smallpox 410 

Scarlet  fever 411 

Measles .  412 

Mumps .  412 

Whooping  cough 413 

Influenza 413 

Diphtheria 414 


CONTENTS.  XV 

PAGE 

Intubation 416 

Tracheotomy 417 

Post-diphtheritic  paralysis 418 

Cerebro-spinal  meningitis 418 

Erysipelas 419 

Cholera 420 

Yellow  fever 422 

Pyaemia  and  septicaemia         . 426 

Malarial  fevers 426 

Tetanus 427 

Rabies 428 

Tuberculosis 428 

General  considerations 429 

Diet  in  mild  cases 434 

Foods  allowed  in  non-active  cases  without  gastric  catarrh     ....  435 

Diet  in  advanced  cases 436 

Milk  diet 437 

Suralimentation 438 

Diet  for  forced  feeding       . 439 

Aids  to  dietetic  treatment 440 

Diet  "  cures  "  for  phthisis 440 

DIET  IN  DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

Laryngismus  stridulus 441 

Tubercular  laryngitis 441 

Haemorrhage  of  the  lungs 442 

Acute  capillary  bronchitis 443 

Chronic  bronchitis 443 

Asthma 444 

Emphysema " 445 

Pneumonia 445 

Broncho-pneumonia 447 

Broncho-pneumonia  in  children .  448 

Pleurisy 44^ 

Empyema 449 

• 

DIET   IN   DISEASES  OF  THE  CIRCULATORY   SYSTEM  AND  BLOOD. 

Diseases  of  the  heart 45° 

Pathological  physiology 450 

Use  of  fluids 451 

Dietetic  treatment 45' 

Cardiac  valvular  disease  in  children 452 

Dietetic  treatment  of  the  senile  heart 453 

Angina  pectoris  ..........•••  45^ 

Cardiac  palpitation 45^ 

Arterial  sclerosis 45^ 

Aneurism 45^ 

Tufnell's  diet 457 

Anaemia. — Chlorosis .458 

Pernicious  anaemia 4^3 


xvi  CONTENTS. 


DIET  IN  DISEASES  OF  THE  URINARY   SYSTEM. 

PACK 

Modifications  in  the  urine  caused  by  food 463 

Acute  nephritis 464 

Acute  nephritis  in  children 466 

Albuminuria. — Functional  albuminuria .  466 

Chronic  Bright's  disease .  470 

Milk  diet .        .471 

Pyelitis 475 

Oxaluria 475 

Calculi,  renal  and  vesical 476 

Lithsemia.     Uric-acid  diathesis. — Gravel 478 

Gonorrhoea    ..............  481 

DIET   IN   DISEASES   OF   THE  ALIMENTARY   CANAL. 

Abnormal  dentition 481 

Catarrhal  stomatitis 482 

Tonsilitis  and  quinsy 482 

Dysphagia 483 

Stricture  and  carcinoma  of  the  oesophagus     ........  484 

Feeding  through  a  gastric  fistula 484 

Foreign  bodies  swallowed 484 

Indigestion  and  dyspepsia 485 

Symptoms 485 

Etiology.     Idiosyncrasies 487 

Examination  of  the  stomach  contents         ........  489 

Test  meals 490 

Tests  for  hydrochloric  acid 491 

Hypersecretion .  493 

Tests  for  pepsin  and  rennin 494 

Test  for  motor  power  of  stomach        .         .         .  • 494 

Test  for  absorptive  power  of  stomach 495 

Dietetic  treatment  of  dyspepsia 496 

Desirable  foods 497 

Beverages 498 

Special  systems  of  treatment 49S 

General  rules  for  dyspeptics 499 

Rules  for  special  varieties  of  dyspepsia 500 

Dyspepsia  in  children "        .  501 

Acute  gastric  catarrh 502 

Gastric  fever  in  children .  504 

Chronic  gastric  catarrh 505 

Pathological  physiology      ...........  505 

Dietetic  treatment .  506 

Milk  diet 506 

Other  diet 507 

Convalescence 509 

Hydrochloric  acid 509 

Chronic  gastric  catarrh  in  children .510 

Dilatation  of  the  stomach. — Gastrectasia 511 

Lavage 513 

Massage 516 

Electricity 517 


CONTENTS.  xvii 

PAGE 

Vomiting 518 

Pathological  physiology .         .51S 

Dietetic  treatment 519 

Seasickness 5ig 

Vomiting  of  pregnancy 521 

Ulcer  of  the  stomach 522 

Cancer  of  the  stomach  . 525 

DIET   IN   DISEASES   OF   THE   INTESTINES. 

Diarrhoea 529 

Pathological  physiology 529 

Dietetic  treatment 529 

Diarrhoea  in  infants  and  young  children 530 

Dietetic  causes 530 

Examination  of  stools 532 

Dietetic  treatment 533 

Entero-colitis  in  infants  and  children.     Summer  diarrhoea   .         ,         .         .         .  534 

Cholera  infantum  or  acute  milk  infection 535 

Cholera  morbus.     Acute  catarrhal  enteritis  in  adults 536 

Chronic  enteritis  in  adults.     Chronic  intestinal  catarrh.     Chronic  colitis     .         .  537 

Chronic  intestinal  indigestion  in  children 538 

Chronic  gastro-intestinal  catarrh.     Chronic  entero-colitis.     Chronic  diarrhoea  in 

children 539 

Simple  atrophy.     Marasmus 540 

Mucous  disease.      Chronic  pseudo-membranous  gastro-enteritis.      Membranous 

enteritis 541 

Dysentery 543 

Chronic  dysentery 544 

Acute  intestinal  obstruction .        .  544 

Chronic  constipation 545 

Physiology .         .         .         -545 

Pathological  physiology 546 

Dietetic    treatment 548 

Summary  of  the  most  useful  articles  of  diet 550 

Foods  to  be  avoided 550 

Aids  to  dietetic  treatment 550 

Constipation  in  infants  and  children 553 

Foods  recommended ............  554 

Foods  forbidden 554 

Hemorrhoids          . .         .  555 

Appendicitis £55 

Causation 555 

Dietetic  treatment      . 55^ 

Acute  j)eritonitis 55^ 

Chronic  peritonitis 557 

DIET   IN   DISEASES   OF   THE   LIVER. 

Diet  in  liver  diseases  in  general 557 

"Biliousness" 557 

Causation 557 

Dietetic  treatment 558 

Directions  for  eating 5^ 


Xviii  CONTENTS. 

PAGE 

Acute  catarrhal  inflammation  of  the  gall  ducts.   Angiocholitis.    Catarrhal  jaundice  561 

Cirrhosis 561 

Dietetic  treatment  of  cirrhosis  without  ascites 562 

Ascites 562 

Dietetic  treatment  of  cirrhosis  with  ascites 563 

Fatty  liver 564 

Amyloid  liver 564 

Syphilis  of  the  liver 565 

Abscess  of  the  liver 565 

Gallstones 565 

Pathological  physiolc^ 565 

Dietetic  treatment 567 

Diet  in  pancreatic  diseases 568 

DIET  IN  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Neuralgia 569 

Causation 569 

Dietetic  treatment      .        .        . .        .        .  569 

Visceral  neuralgia 571 

Gastralgia 571 

Enteralgia .  572 

Hepatalgia 572 

Migraine        .         .         .         . .  573 

Neurasthenia         .        .        .        • 574 

Causation 5^4 

General  treatment 575 

The  "  rest  cure  " 578 

Weir  Mitchell's  diet 579 

Playfair's  diet 580 

Leyden's  diet 580 

Keating's  diet 581 

Insomnia  and  disordered  sleep 582 

Vertigo 583 

Chorea 583 

Epilepsy 583 

Beri-beri 585 

Locomotor  ataxia. 586 

Apoplexy 586 

Acute  insanity.     Melancholia.     Primary  dementia.     Mania          ....  587 

Forced  feeding 588 

DIET   IN   SKIN   DISEASES. 

Skin  diseases  which  are  caused  by  improper  diet 591 

General  principles  of  dietetic  treatment 592 

Erythema.     Urticaria 502 


Acne 
Eczema . 


593 
594 


Cases  due  to  overeating 594 

Typical  diet  for  eczema 594 

Cases  due  to  insufficient  food 595 

Cases  due  to  improper  food 595 

Eczema  in  nursing  infants 596 


CONTENTS.  xix 

PAGE 

Eczema  in  children 5g7 

Exfoliative  dermatitis 597 

Rosacea jgy 

Psoriasis 598 

Pruritus 598 

Furunculosis 598 

DISEASES  ESPECIALLY  INFLUENCED   BY  DIET. 

Obesity  (Polysarcia) 599 

Causation 599 

Dietetic  treatment 601 

Systems  of  Banting 603 

Ebstein 604 

Oertel 605 

Schweninger  .............  6og 

Schleicher       . 610 

Germain  S6e  . 610 

Weir  Mitchell 610 

Yeo 611 

Dujardin-Beaumetz 612 

Meat  and  hot-water  treatment 612 

System  of  Bouchard 613 

System  of  Chambers 613 

"  Anti-fat  "  remedies 615 

Diet  for  leanness 615 

Rheumatism,  acute 617 

Chronic 618 

Rheumatoid  arthritis 6i3 

Gout 619 

Causation 619 

Preventive  treatment 621 

Theory  of  dietetic  treatment 622 

Diet  for  the  gouty  diathesis  and  chronic  gout 624 

Beverages 628 

Diabetes  mellitus . 631 

Causation 633 

Relation  to  gout  and  other  diseases 634 

Physiological  experiments  .         .         .         •         •         •         •         •         •         -635 

The  nervous  system  and  diabetes      .........  638 

The  circulation  and  diabetes 639 

Various  theories         .......•••••  639 

Symptoms ^40 

Course        ..........••••  ^44 

Dietetic  treatment 646 

Foods  allowed ^5 1 

Foods  forbidden "53 

Substitutes  for  bread ^53 

Substitutes  for  sugar "57 

Beverages ^5^ 

Special  diets ^59 

Skimmed  milk ^59 

Ebstein's  diet .        .        .        .     ' 660 


xz 


CONTENTS. 


PAGE 

Diiring's  diet 66i 

Naunyn's  diet 6Ci 

Scrofula 662 

Rhachitis  (rickets) 664 

Aids  to  dietetic  treatment 667 

Diet  in  scurvy 668 

Causation  ..............  668 

Haemorrhagic  purpura  .         .         .         .         . 671 

DIET   IN   MISCELLANEOUS   DISEASES. 

Addison's  disease 671 

Osteomalacia. 672 

Exophthalmic  goitre .  672 

Chronic  lead  poisoning  ............  672 

Drug  habits.     Morphinism,  etc 673 

Dietetic  complications  arising  from  associated  diseases 673 

DIET   FOR    SURGICAL    PATIENTS. 

Food  and  anaesthetics    .         .         ... 674 

Diet  after  anaesthesia ,         .         .         .  675 

Surgical  operations  and  injuries          . 676 

Laparotomy.     Ovariotomy         ..........  677 

Surgical  inflammation.     Sepsis 678 


PART   IX. 

RATIONS. — DIETARIES. 

Army  and  navy  diets ■ 680 

The  U.  S.  army  rations 680 

U.  S.  army  ration  in  the  field     ..........  6S2 

U.  S.  army  travel  ration     ...........  683 

Garrison  ration  for  ten  days 683 

Foreign  army  rations 684 

Navy  rations 686 

Diet  in  prisons       .............  688 

U.  S.  army  prison  diet        ...........  688 

New  York  State  Reformatory  diet 690 

Dietetic  cures         .•■•......... 

Milk  cure 694 

Whey  cure 697 

Various  ' '  cures  " 698 

Kneipp  system 699 

Fruit  cures 690 

Grape  cure 699 

Meat  and  hot-water  cure 701 

Dry  cure 702 

Schroth's  method        ............  702 

Athletic  training 703 

Dietary  of  the  Yale  boat  crew 705 

Dietary  of  the  Yale  football  team 707 


CONTENTS.  xxi 

PAGE 

Diet  and  occupation 707 

Brain  workers     .............  708 

Commercial  life .         .         . 711 

Travel         ..............  712 

Diet  in  pregnancy  .         .         .         .         .         .         .         .         .         .         .         .713 

Diet  for  puerperal  women 714 

Selection  of  a  wet  nurse 716 

Diet  of  a  nursing  mother  or  wet  nurse  . 717 

Drugs  in  human  milk 718 

Food  of  infants 718 

Size  of  the  infant  stomach 718 

Overfeeding 719 

Methods  of  feeding 719 

Feeding  by  the  mother  or  wet  nurse .........  719 

Feeding  by  the  bottle         ...........  720 

Mixed  feeding    .............  724 

Weaning 724 

Artificial  infant  foods 729 

Infant  stools 730 

Nursing  bottles  .............  730 

Care  of  infant's  mouth 731 

Weighing  of  infants * 731 

Premature  infants       ............  732 

Food  for  young  children        ...........  732 

Rules  for  feeding  young  children        .........  734 

Dietaries  for  young  children       ..........  735 

Teething  and  food      ............  739 

Sleep  and  food 739 

Diet  for  school  children          ...........  740 

Hours  for  meals          ............  741 

Hospital  dietaries .............  747 

The  New  York  Hospital 750 

Presbyterian  Hospital 751 

Bellevue,  Gouvemeur,  Fordham,  and  Harlem  Hospitals 755 

Roosevelt  Hospital 757 

Johns  Hopkins  Hospital 758 

Cook  County  Hospital 758 

Liverpool  Infirmary 758 

New  York  Infirmary 758 

New  York  State  Hospital 759 

Utica  State  Hospital  for  Insane 760 

Dietaries  of  army  hospitals 763 

United  States 763 

British,  Prussian 764 

French 765 

APPENDIX. 
Receipts  for  invalid  food  and  beverages  suitable  for  fevers  and  convalescence 

from  acute  illness 767 

Beverages 767 

Demulcent  and  nutritive 767 

Diuretic  and  refrigerant 76S 


xxii  CONTENTS. 

PACB 

Fluid  beef  preparations 769 

Broths  and  soups 771 

Solid  meat  preparations 772 

Milk  preparations .............  773 

Egg  preparations 775 

Farinaceous  foods 777 

Gelatin  preparations 780 


LIST   OF   ILLUSTRATIONS. 

Plate     I.  Milk  laboratory Facing  78 

"        II.  Animal  fats  (butter  and  butterine) Facing  84 

"      III.  Starch  granules  (wheat,  barley,  rye,  oats,  corn,  and  rice)     ,       Facing  118 

"       IV.  Maize  starch  and  wheat  starch     .         .         .         .         .         .       Facing  120 

Section  through  wheat  kernel      .         .         .         .         .         .         .         .120 

Microscopic  characters  of  wheat 120 

"        V.  Rice  starch  .         .    ' Facing  138 

"      VI.  Starch  granules  (marunta,  potato,  ginger,  sago,  peas,  and 

beans) Facing  141 

"     VII.  Bean  starch  and  pea  starch .         .         .         .         .         .         .       Facing  146 

"  VIII.  Potato  starch Facing  148 

"      IX.  Animal  fats  (beef  fat  and  oleomargarine)     ....       Facing  172 

Comparison  of  daily  dietaries 692 

Diet  sheet .  754 


PRACTICAL    DIETETICS. 

PART   I. 

FOODS    AND     FOOD     PREPARATIONS. 

lOlli . 

ELEMENTARY    COMPOSITION    OF    FOODS. 

Of  the  seventy-three  chemical  elements,  thirteen  enter  uniformly 
into  the  composition  of  the  body  and  ten  more  are  occasionally 
found.  Of  all  these,  several  exist  in  very  small  proportion  and 
their  uses  are  unknown,  several  are  found  more  abundantly  but 
are  not  indispensable  to  life,  and  certain  elements — namely,  carbon, 
hydrogen,  oxygen,  and  nitrogen — are  necessary  ingredients  of  the 
tissues  of  the  body.  These  elements  form  compounds  which,  as 
they  occur  in  the  structure  of  the  various  tissues,  have  the  following 
characteristics : 

First,  although  the  elements  are  but  few  in  number,  their  molecu- 
lar arrangement  is  very  complex. 

Second,  their  compounds  are  comparatively  unstable  and  are 
readily  converted  in  the  body  or  by  chemical  analysis  into  other 
forms. 

All  food  is  composed  of  combinations  of  these  simpler  chemi- 
cal elements  which,  for  the  most  part,  must  be  subjected  to  altera- 
tion in  the  body  itself  to  prepare  it  for  assimilation  by  the  tis- 
sues. The  nutrition  of  the  body,  therefore,  involves  several  distinct 
processes,  viz. : 

1.  The  secretion  of  digestive  fluids  and  their  action  upon  food  in 
the  alimentary  canal. 

2.  The  absorption  of  the  ingredients  of  the  food  when  digested 
into  the  blood  and  lymphatic  vessels. 

3.  The  assimilation  of  the  absorbed  nutritious  products  by  the 
tissues. 

4.  The  elimination  of  the  waste  material. 

The  analysis  given  below  exhibits  admirably  the  relative  predom- 
inance of  the  elements  of  which  the  human  body  is  composed. 
3  1 


2  FOODS   AND   FOOD   PREPARATIONS. 

Approximate  Analysis  of  a  Man  (Moss). 

(Height,  5  feet  8  inches  ;  weight,  148  pounds.) 

Oxygen 92-4  pounds. 

Hydrogen 14.6 

Carbon 31 -6 

Nitrogen 4-6 

Phosphorus 1-4 

Calcium 2.8 

Sulphur 0.24     " 

Chlorine 0.12     " 

Sodium 0.12     " 

Iron 0.02     " 

Potassium 0.34     " 

Magnesium •  0.04     " 

Silica ? 

Fluorine 0.02     " 

Total 148.00  pounds. 

All  these  elements  are  necessarily  derived  from  food  plus  the 
oxygen  of  the  air  which  is  breathed. 

The  three  predominating  elements — oxygen,  hydrogen,  and  carbon 
— are  the  great  force  producers  of  the  body,  although  they  are  tissue 
formers  as  well,  and  to  them  must  be  added  nitrogen,  as  serving  in 
this  double  capacity,  although  its  relation  to  tissue  formation  and  re- 
newal is  greater  than  its  capacity  for  supplying  energy. 

The  common  elements  which  enter  into  tissue  formation  chiefly 
and  which  bear  no  direct  relation  to  the  main  sources  of  the  force 
production  in  the  body  are  chlorine,  sulphur,  phosphorus,  iron,  sodium, 
potassium,  calcium,  and  magnesium  in  different  combinations.  Bone 
tissue,  for  example,  contains  about  50  per  cent,  of  lime  phosphate. 
If  this  substance  is  deficient  in  the  food  of  the  young  growing  infant, 
the  bones  are  poorly  developed  and  so  soft  that  they  yield  to  the 
strain  of  the  weight  of  the  body  and  become  bent  and  out  of  shape. 
This  constitutes  one  of  the  principal  symptoms  of  rickets. 

Lack  of  iron  salts  in  the  food  impoverishes  the  colouring  matter 
of  the  red  blood-corpuscles  on  which  they  depend  for  their  power  of 
carrying  oxygen  to  the  tissues,  and  anaemia  and  other  disorders  of 
deficient  oxidation  result. 

The  lack  of  sufficient  potash  salts,  especially  potassium  carbonate 
and  chloride,  is  a  factor  in  producing  scurvy,  and  the  condition  is  ag- 
gravated by  the  use  of  common  salt  (Nace).  A  diet  of  salt  meat 
and  starches  may  cause  it  with  absence  of  potatoes  and  fresh  fruit 
and  vegetables. 

The  lack  of  sodium  chloride  interferes  with  many  of  the  functions 
of  the  body  immediately  concerned  with  nutrition,  such  as  absorption 
(osmosis),  secretion,  etc.,  and  alters  the  density  and  reactions  of  the 
different  fluids. 


ELEMENTARY   COMPOSITION   OF   FOODS.  3 

These  few  illustrations  suggest  the  diversity  of  roles  exhibited  by 
the  elements  and  the  need  for  a  correctly  balanced  diet. 

In-order  to  determine  what  such  a  diet  should  consist  of  it  is  ne- 
cessary to  study  the  value  of  the  principal  classes  of  foods  in  force 
production  and  in  nutrient  power  or  tissue  building,  but  before  pro- 
ceeding further  with  this  discussion  it  will  be  advisable  to  adopt  a  sim- 
ple comprehensive  classification  of  the  foods  in  general  use  by  man. 

The  following  table  of  analyses  made  by  Dujardin-Beaumetz  is 
quoted  by  Yeo  to  show  the  proportion  of  nitrogen  present  in  differ- 
ent foods,  and  also  the  combustible  carbon  and  hydrogen. 

"  The  hydrogen  existing  in  the  compound  in  excess  of  what  is  re- 
quired to  form  water  with  the  oxygen  present  is  calculated  as  carbon. 
It  is  only  necessary  to  multiply  the  nitrogen  by  6.5  to  obtain  the 
amount  of  dry  proteids  in  100  grammes  of  the  fresh  food  substance :  " 


Beef (uncooked) 

Roast  beef. 

Calf's  liver 

Foie-gras 

Sheep's  kidneys 

Skate 

Cod,  salted 

Herring,  salted 

Herring,  fresh 

Whiting 

Mackerel 

Sole 

Salmon 

Carp 

Oysters 

Lobster  .(uncooked) 

Eggs 

Milk  (cow's) 

Cheese  (Brie) 

Cheese  (Gruyfere) 

Cheese  (Roquefort) 

Chocolate 

Wheat  (hard  southern,  variable  average).. 
Wheat  (soft  southern,  variable  average) . . 

Flour,  white  (Paris) 

Rye  flour 

Winter  barley 

Maize 

Buckwheat 

Rice 

Oatmeal 

Bread,  white  (Paris,  thirty  per  cent  water) 
Bread,  brown  (soldiers'  rations  formerly). 
Bread,  brown  (soldiers'  rations  at  present) 

Bread  from  flour  of  hard  wheat 

Potatoes 

Beans 

Haricots  (dry) 

Lentils  (dry) 

Peas  (dry) 


C  +  H. 

Nitrogen. 

Combustibles  cal- 

culated as  carbon. 

3-00 

11.00 

3.53 

17.76 

3  09 

15.68 

2.12 

65-58 

2.66 

12.13 

3-S3 

12.25 

5.02 

16.00 

311 

23.00 

1.83 

21.00 

2.41 

9.00 

3-74 

19.26 

1. 91 

12.25 

2.09 

16.00 

3-49 

12.10 

2.13 

7.18 

2.93 

10.96 

1.90 

13-50 

0.66 

8.00 

2.93 

35.00 

5.00 

38.00 

4.21 

44-44 

1.52 

58.00 

3.00 

41.00 

1. 81 

39-00 

1.64 

38.50 

1-75 

41.00 

1.90 

40.00 

1.70 

44.00 

2.20 

42.50 

1.80 

41.00 

1-95 

44.00 

1.08 

29-50 

1.07 

28.00 

1.20 

30.00 

2.20 

31. CO 

0.33 

II  00 

4.50 

42  00 

3.92 

43-00 

3-87 

43- 00 

3.66 

44-00 

FOODS   AND   FOOD   PREPARATIONS. 


Carrots 

Mushrooms 

Figs  (fresh) 

Figs  (dry) 

Plums 

Coffee  (infusion  of  ico  grammes) 
Tea  (infusion  of  lOO  grammes).  . 

Bacon  

Butter  (fresh) 

Olive  oil 

Beer,  strong 

Wine 


Nitrogen. 

C  +  H. 
Combustibles  cal- 
culated as  carbon. 

0.31 
0.60 

5-50 
4-52 

0.41 
0.92 
0.75 

15-50 
34-00 
28.00 

1. 10 

9.00 

1. 00 

10.50 

1.29 
0.64 
Trace 

71.14 
83.00 
98.00 

0.05 
0.15 

4-50 
4.00 

To  estimate  the  equivalent  chemical  elements  in  the  different 
classes  of  foods  Parkes  gives  the  following  simple  rules : 

1.  To  obtain  the  amount  of  nitrogen  in  proteid  foods,  divide  the 
quantity  of  food  by  6.30. 

2.  To  obtain  the  carbon  in  fat,  multiply  by  0.79. 

3.  To  obtain  the  carbon  in  carbohydrate  food,  multiply  by  0.444. 

4.  To  obtain  the  carbon  in  proteid  food,  multiply  by  0.535. 

Estimates  vary  somewhat  as  to  the  average  quantity  of  the  ele- 
ments carbon  and  nitrogen  consumed  per  diem.  In  a  general  way  it 
may  be  said  that  the  consumption  of  carbon  is  320  grammes,  and 
that  of  nitrogen  about  20  grammes.     (See  Quantity  of  Food.) 


FOOD    CLASSIFICATION. 

Foods  may  be  classified  in  various  ways,  according  to — 

1.  Their  physical  properties. 

2.  Their  source. 

3.  Their  composition. 

4.  The  role  which  they  perform  in  the  animal  body. 

Foods  are  classed  in  accordance  with  their  general  physical 
properties :  First,  into  solid,  semisolid,  and  liquid  foods  ;  secondly, 
into  fibrous,  gelatinous,  starchy,  oleaginous,  and  albuminous  foods. 

A  subdivision  sometimes  used  is  that  of  the  "  complete  "  foods, 
such  as  eggs  and  milk  which  in  a  single  article  comprise  all  the 
necessary  ingredients  and  elements  to  support  life,  and  "incom- 
plete "  foods,  which  are  capable  of  maintaining  life  but  a  compara- 
tively short  time. 

Foods  may  be  classed  as  to>  their  source  primarily  into  animal 
and  vegetable  foods. 

Animal  foods  consist  of  meats,  fowl,  fish,  shell  fish,  and  crusta- 
ceans, eggs,  milk  and  its  products,  animal  fats,  gelatin.  The  vege- 
table foods  are  subdivided  into  cereals,  vegetables  proper,  fruits, 
sugars,  vegetable  oils. 


FOOD   CLASSIFICATION, 


.5 


The  simplest  chemical  classification  possible  is  that  advocated  by- 
Baron  von  Liebig,  who  was  the  first  to  suggest  a  really  scientific 
division  of  foods.     He  grouped  all  foods  into  two  classes — 

a.   Nitrogenous,     b.  Non-nitrogenous. 

Each  of  these  classes  contains  food  materials  derived  from  both 
the  animal  and  vegetable  kingdoms,  although  the  majority  of  the 
animal  substances  belong  to  the  nitrogenous,  and  the  majority  of 
vegetable  substances  to  the  non-nitrogenous  group. 

a.  The  nitrogenous  group  von  Liebig  regarded  as  containing 
*'  plastic  "  elements — i.  e.,  they  are  essentially  "  tissue  builders  "  or 
"flesh  formers." 

Nitrogenous  foods  are  sometimes  called  "  azotised  foods  "  or 
"  albuminoids  " — that  is,  substances  resembling  albumin.  They  con- 
sist chiefly  of  the  four  elements  carbon,  oxygen,  hydrogen,  and 
nitrogen,  to  which  a  small  proportion  of  sulphur  and  phosphorus  are 
usually  joined.  These  elements  for  the  most  part  are  combined  as 
some  form  of  albumin. 

Nitrogenous  or  proteid  foods  are  non-crystallisable,  but  coagula- 
ble,  principally  fluid  or  semisolid  substances.  They  are  fermenta- 
ble, and  under  some  conditions  will  putrefy. 

The  nitrogenous  group  comprises  all  forms  of  animal  food,  ex- 
cepting fats  and  glycogen.  It  includes,  therefore,  albumins  and  gela- 
tins. Its  chief  representatives  are  milk,  eggs,  crustaceans,  fish,  shell 
fish,  flesh,  and  fowl.  It  also  contains  such  nitrogenous  substances  as 
occur  in  the  vegetable  kingdom  or  **  vegetable  albuminoids." 

b.  The  second  or  non-nitrogenous  group  von  Liebig  called 
"  respiratory  or  calorifacient  foods,"  because  their  function  in  the 
body  is  to  furnish  fuel  or  maintain  animal  heat.  Since  this  original 
classification  was  suggested  it  has  been  established  that  the  non- 
nitrogenous  aliments  supply  energy  as  force,  manifested  through 
muscular  action,  hence  they  are  also  called  "  force  producers,"  in 
distinction  from  the  nitrogenous  "  tissue  formers." 

This  is  a  convenient  distinction  to  adopt,  but  it  must  not  be  held 
too  absolutely,  for  in  emergencies  the  tissue  builders  are  used  as 
force  producers  and  heat  givers  as  well. 

The  non-nitrogenous  group  contains  strictly  only  the  three  ele- 
ments carbon,  hydrogen,  and  oxygen,  although  various  salts  are 
mixed  with  both  vegetable  and  animal  foods.  It  includes  all  forms 
of  vegetables  and  fruits,  cereals,  starches,  sugars,  gums,  fats  and 
oils,  which  are  both  animal  and  vegetable,  and  organic  acids.  Many 
vegetables,  besides  some  fruits,  contain  considerable  nitrogen. 
Many  of  the  vegetables,  and,  in  fact,  all  the  starch  granules,  contain 
a  certain  proportion  of  nitrogenous  material  which  is  chiefly  used  in 
the  formation  of  outside  coverings  for  the  purpose  of  giving  protec- 
tion and  affording  firmness  of  resistance  to  a  softer  pulp  within. 


6  FOODS   AND   FOOD   PREPARATIONS. 

Neither  is  animal  food  strictly  nitrogenous,  on  account  of  its  fat 
and  glycogen,  nor  is  vegetable  food  strictly  non-nitrogenous,  owing 
to  its  albuminoids  and  other  forms  of  proteids,  yet  this  classification 
is  a  very  convenient  and  simple  one  which  has  met  with  general 
acceptance.  It  will  be  used  in  this  book  whenever  a  further  degree 
of  subdivision  is  not  needed,  but  always  with  the  understanding  that 
it  has  only  a  general  and  not  too  literal  application,  and,  unless 
otherwise  distinctly  specified,  "  nitrogenous  food  "  will  be  understood 
to  include  animal  food,  and  "non-nitrogenous  food"  to  include 
vegetable  food  of  all  kinds,  and  vice  versa. 

The  following  analyses  by  Hofmann  and  Parkes  of  several  com- 
mon foods  illustrate  the  mixed  character  of  animal  and  vegetable 
foods  and  the  difficulties  of  a  purely  chemical  basis  of  classification  : 

Table  of  Composition  of  Some  Common  Foods. 
(Hofmann.) 


Nitrogenous 
constituents. 

Fat. 

Carbo- 
hydrates. 

Salts. 

Total. 

Fat  beef 

51-4 
89.4 
27-3 
16.6 

7-7 

45.6 

5-5 
0.8 
0.9 
0.4 

68^9 

81.9 

91.2 

3-0 
5-1 

30 
0.6 
0.7 

100 

100 

Pea  flour    

ICO 

Wheat 

100 

Rice 

100 

Table  of  Composition  of  Common  Foods. 
(Abridged  from  Parkes.) 


Articles. 


Beefsteak 

Fat  pork 

Smoked  ham 

Whitefish 

Poultry 

White  wheat  in  bread. . . .    . 

Biscuit 

Oat  meal 

Maize 

Macaroni 

Arrowroot 

Peas  (dry) 

Potatoes 

Carrots 

Cabbages 

Butter 

Egg  (i-io  for  shell) 

Cheese 

Milk  (specific  gravity,  1032), 

Cream 

Skimmed  milk 

Sugar 


Water. 

Proteids. 

Fats. 

Carbo- 
hydrates. 

74-4 

20.5 

3-5 

39-0 

9.8 

48.9 

27.8 

24.0 

36.5 

78.0 

18. 1 

2.9 

74.0 

21.0 

3-8. 

40.0 

8.0 

1-5 

49.2 

8.0 

15.6 

1-3 

73.4 

I5-0 

12.6 

5-6 

63.0 

13-5 

10. 0 

6.7 

64-5 

I3-I 

9.0 

0.3 

76.8 

15-4 

0.8 

83.3 

I5-0 

22.0 

2.0 

53-0 

74.0 

2.0 

0.16 

21.0 

85.0 

1.6 

0.25 

8.4 

91.0 

1.8 

5-0 

5-8 

6.0 

0.3 

91.0 

73-5 

13-5 

II. 6 

36.8 

33-5 

24-3 

86.8 

4.0 

3-7 

4.8 

66.0 

2.7 

26.7 

2.8 

88.0 

4.0 

1.8 

5-4 

3-0 

96- 5 

Salts. 


FORCE  PRODUCTION.  ENERGY  FROM  FOOD.         y 

Another  classification  is  that  of  Prout,  who  grouped  foods  as 
follows : 

I.  Aqueous.     2.  Saccharine.     3.  Oleaginous.     4.  Albuminous. 

This  arrangement  fails  to  provide  separate  groups  for  salines, 
starches,  and  gelatinous  substances. 

For  the  purpose  of  the  present  work,  it  is  found  convenient  to 
subdivide  foods  more  accurately,  and  the  following  classification  is 
adopted  : 

I.  Water. 

II.  Salts. 

III.  Proteids  (chiefly  albumins  and  the  allied  gelatin). 

IV.  Starches. 

V.  Sugars. 

VI.  Fats  and  oils. 

Some  writers  class  oxygen  in  a  separate  division  among  foods. 
This  seems  hardly  necessary,  unless  one  is  to  make  a  separate  divi- 
sion for  hydrogen,  and  in  fact  for  each  element. 

The  primary  object  of  food  classification  is  to  obtain  a  practical 
working  basis  of  subdivision,  and  the  less  complex  this  is  made,  the  bet- 
ter. Further  details  of  grouping  belong  to  the  refinements  of  physio- 
logical or  organic  chemistry,  and  are  out  of  place  in  the  present  work. 

FORCE    PRODUCTION.     ENERGY    FROM    FOOD. 

The  two  ultimate  uses  of  all  food  are  to  supply  the  body  with 
materials  for  growth  or  renewal,  and  with  energy  or  the  capacity  for_ 
doing  work.  The  energy  received  in  a  latent  form,  stored  in  the 
various  chemical  combinations  of  foods,  is  liberated  as  kinetic  or 
active  energy  in  two  chief  forms :  first,  as  heat ;  second,  as  motion. 
Force  is  the  manifestation  of  energy.  The  force  developed  by  a 
healthy  adult  man  at  ordinary  labour  averages  3,400  foot  tons  per 
diem,  a  foot  ton  being  the  amount  of  force  required  to  raise  a  weight 
of  one  ton  through  the  height  of  one  foot.  Of  this,  somewhat  less 
than  one  fifth  is  expended  in  motion,  and  somewhat  more  than  four 
fifths,  or  2,840  foot  tons,  in  heat,  which  maintains  the  body  tempera- 
ture at  its  normal  average. 

A  man  weighing  one  hundred  and  fifty  pounds — or  over  one 
thirteenth  of  a  ton— obviously  expends  considerable  energy  in 
merely  moving  his  own  body  about  from  place  to  place,  aside  from 
carrying  any  additional  burden. 

The  original  force  developed  in  the  various  functions  of  animal 
life  which  result  in  heat  production  and  motion  is  chiefly  obtained 
from  the  radiant  heat  of  the  sun  stored  by  plants  in  the  latent  form 
of  certain  chemical  compounds — chiefly  starches  and  sugars — which, 
on  being  consumed  as  food  by  animals,  furnish  energy. 


8  FOODS  AND  FOOD   PREPARATIONS. 

A  useful  comparison  may  be  made  between  the  processes  of  nu- 
trition and  development  of  energy  from  food  in  the  human  body 
and  the  energy  derived  from  a  steam  engine  and  boiler.  In  both 
cases  the  main  source  of  energy  is  oxidation,  and  principally  of  car- 
bon. In  both  cases  the  latent  energy  of  the  carbon  liberated  by 
oxidation  processes  is  converted  into  heat  and  motion,  forms  of 
energy  which  bear  a  definite  relation  to  one  another.  If  a  large 
part  of  the  original  latent  energy  is  converted  into  heat,  less  will 
yield  motion,  and  conversely.  The  proportion  of  these  two  forces 
to  each  other  is  in  the  case  of  the  most  perfectly  constructed  en- 
gine about  one  of  motion  to  eight  of  heat ;  whereas  in  the  human 
body  it  was  calculated  by  Helmholtz  that  the  motion  obtainable 
from  a  given  amount  of  food  may  stand  in  relation  to  the  heat  in 
the  proportion  of  one  to  five.  Hence,  as  regards  the  production  of 
work  through  motion,  the  human  body  is  a  more  perfectly  con- 
structed machine  than  the  engine.  Furthermore,  after  combustion 
of  the  carbon  by  the  fires  of  the  boiler  a  certain  amount  of  waste 
matter  or  ash  is  produced.  If  this  is  allowed  to  accumulate,  it 
obstructs  the  draught  and  interferes  with  active  oxidation.  In  the 
human  body,  in  like  manner,  the  fuel  or  food  consumed  produces 
ashes,  such  as  urea  and  other  forms  of  waste  material,  which,  if  not 
removed,  accumulate  in  the  system  and  embarrass  or  retard  the 
normal  oxidation  processes.  The  body  possesses  the  additional 
power  of  sorting  and  modifying  the  fuel  food  which  it  receives  so 
as  to  develop  its  energy  to  the  best  advantage  in  different  organs. 

Whether  elementary  substances  are  burned  outside  of  the  body 
or  oxidised  within  the  body,  the  resulting  products  are  the  same. 
There  can  be  no  loss  of  matter,  and  there  can  be  no  loss  of  energy. 
The  matter  is  simply  changed  in  form  by  molecular  rearrangement, 
the  energy  is  converted  from  one  type  into  another.  The  following 
simple  experiment  will  illustrate  this  point :  In  a  large  covered  glass 
jar  place  an  ounce  of  alcohol  in  a  small  metal  vessel.  Also  place  in 
the  jar  a  little  lime  water  in  a  tumbler,  and  a  thermometer.  On 
Igniting  the  alcohol  and  allowing  it  to  burn  away  completely,  a  film  of 
aqueous  vapour  will  accumulate  on  the  surface  of  the  jar,  and  a  film 
of  calcium  carbonattf'Will  form  on  the  surface  of  the  lime  water  pro- 
duced by  the  union  of  carbonic-acid  gas  with  the  lime  water.  The 
thermometer  will  indicate  a  rise  in  temperature  of  the  air  in  the  jar. 
An  ounce  of  alcohol  consumed  as  food  will  be  similarly  converted 
into  carbonic-acid  gas  and  water,  and  in  this  process  the  body  heat 
will  be  increased,  l^o  substance  is  a  good  food  unless  it  fulfils  two 
conditions — viz.,  easy  assimilation  and  complete  combustion.- 

The  relative  importance  of  the  different  food  fuels  should  be 
considered.     This  is  well  summarised  by  Woodruff : 

"  For  instance,  cut  off  the  supply  of  oxygen,  and  death  ensues  in 


FORCE    PRODUCTION.     ENERGY   FROM    FOOD.  o 

from  one  to  ten  minutes.  If  water  is  withheld,  preventing  the  trans- 
portation of  the  fuel  and  oxygen  to  various  parts  of  the  body,  death 
follows  in  about  two  to  seven  days  or  more,  according  to  climate, 
exposure,  and  exercise.  If  the  fuel  itself  is  taken  away,  death  follows 
in  from  seven  to  forty  days  or  more,  according  to  the  amount  of 
exposure  that  would  abstract  heat  and  the  amount  of  work  that 
would  use  up  the  energy  already  stored  up  in  the  body.  If  materials 
for  the  repair  of  tissues  be  excluded,  death  follows  in  a  variable  time, 
dependent  upon  the  importance  of  the  tissue  that  is  being  starved — 
a  time  varying  from  a  week  if  all  nitrogen  is  excluded,  to  several 
months  if  the  vegetable  acids  are  excluded,  or  even  to  several  years  " 
— if  certain  more  obscure  substances  are  withheld. 
/  It  still  remains  extremely  difficult  in  the  case  of  all  foods  to 
trace  their  final  uses  in  the  body  and  determine  with  any  approach 
to  accuracy  what  proportions  of  each  furnish  respectively  energy, 
repair  of  tissue,  and  heat,  for  there  are  no  more  complex  chemical 
processes  known  than  those  of  tissue  metabolism. 

In  order  to  study  the  quantity  of  energy  which  may  be  derived 
from  different  varieties  of  food,  a  man  or  an  animal  may  be  placed 
in  an  apparatus  known  as  a  calorimeter.  This  apparatus  is  con- 
structed as  follows:  It  consists  of  a  large  dpuble  box  surrounded  by 
one  or  more  jackets  of  non-conducting  material,  such  as  asbestos. 
The  space  between  the  double  layers  of  the  box  is  filled  with  water, 
and  an  animal  is  placed  inside  of  the  box  and  supplied  with  air  at  a 
uniform  temperature.  A  measured  quantity  of  food  is  given.  All 
the  excretions  of  the  animal  are  then  collected,  carefully  weighed, 
measured,  and  compared  with  the  bulk  of  ingested  food.  The  tem- 
perature of  the  water  in  the  walls  of  the  calorimeter  will  be  found  to 
have  risen  after  some  time,  and  the  amount  of  heat  developed  in 
order  to  raise  the  temperature  of  this  water  through  a  certain  num- 
ber of  degrees  is  quickly  calculated.  In  this  manner  may  be  estab- 
lished the  relations  of  different  diets  to  heat  production.  The  unit 
of  measurement  used  is  the  calorie,  which  is  the  amount  of  heat  re- 
quired to  raise  i  kilogramme  of  water  from  o°  to  i°  C,  which  equals 
1.53  foot  tons.  •' "" 

It  is  a  more  complex  problem  to  establish  the  same  relation  in 
regard  to  motion,  but  it  may  be  ascertained  in  a  general  way  by 
feeding  men  or  animals  upon  a  known  and  measured  quantity  of 
food,  and  requiring  them  to  perform  muscular  work. 

Elaborate  investigations  have  been  made  with  all  the  principal 
classes  of  foods  in  order  to  estimate  their  nutrient,  their  heat-pro- 
ducing, and  their  force-producing  value,  and  many  tables  have  been 
issued  furnishing  statistics  of  this  character.  It  should  be  remem- 
bered that  all  this  work  is  merely  approximate,  and  that  the  liability 
to  error  in  the  various  factors  is  considerable,  but  in  a  general  way 


lO  FOODS  AND  FOOD  PREPARATIONS. 

the  results  are  instructive,  and  they  are  certainly  interesting  and  not 
altogether  without  practical  application. 

The  mere  calculation  of  the  nitrogen  and  carbon  in  a  food  does 
not  at  all  show  its  force  value  in  the  body,  unless  it  can  at  the  same 
time  be  demonstrated  that  it  is  assimilable.  Many  substances  appear 
to  contain  abundant  food  energy  which  in  reality  are  not  economical 
foods  at  all  from  the  point  of  view  of  supplying  all  the  needs  of  the 
body;  thus  beef  fat  is  wholesome,  but  it  contains  no  nitrogen  for 
tissue  building,  and  peas  contain  a  large  proportion  of  flesh  formers 
as  compared  with  heat  givers.  Wood  pulp  can  be  made  to  furnish 
cellulose  and  yield  much  energy,  but  it  is  worse  than  useless  in  the 
stomach  of  man,  although  some  of  the  lower  animals,  like  rodents, 
can  digest  it  and  make  it  available  for  nutrition.  Sugar  can  be 
made  from  old  rags  in  the  laboratory,  yet  no  stomach  can  deal  with 
such  material. 

Tables  are  now  available  for  the  calculation  of  the  force  value 
of  rations  for  large  bodies  of  men  under  different  conditions,  as,  for 
example,  soldiers  in  barracks  or  on  the  march,  which  are  based  upon- 
the  principle  of  careful  comparisons  between  the  income  and  output 
of  energy  of  the  body.  That  is  to  say,  a  study  of  the  force-producing 
value  of  different  classes  of  foods,  as  obtained  by  chemical  research 
in  the  laboratory,  is  carefully  compared  with  the  amount  of  waste 
matter  which  is  eliminated  by  the  system  while  a  man  is  being  fed 
upon  a  measured  quantity  of  food  and  kept  under  uniform  conditions 
as  regards  the  amount  of  work  performed.  In  this  manner  a  check 
is  established  upon  the  theoretical  calculations  of  food  values  as  com- 
pared with  their  practical  uses  in  maintaining  the  equilibrium  of  the 
body.  Obviously  these  experiments  require  great  care  and  system, 
and  if  they  are  to  be  made  of  intrinsic  value  they  can  only  be  con- 
ducted by  expert  physiological  chemists  upon  persons  who  are  willing 
to  subject  themselves  from  periods  varying  from  several  days  to 
several  weeks  to  conditions  involving  monotony  of  diet  and  ex- 
istence. For  this  reason  the  number  of.  actual  experiments  of 
this  kind  which  have  been  made  is  comparatively  small,  and  the 
conclusions  drawn  from  them  must  be  accepted  with  considerable 
allowance  for  possible  error.  A  diet  system  to  which  a  man  may  be 
willing  to  submit  for  a  few  weeks  is  by  no  means  always  that  which 
w^ill  prove  best  for  him  through  a  longer  period,  and  a  too  rigid  ap- 
plication of  the  rules  established  for  the  computation  of  the  force 
value  of  foods  yields  much  less  practical  results  than  the  experience 
derived  by  those  who  actually  control  the  commissary  department 
with  due  regard  to  proper  economy  and  variation  in  food,  but  entire- 
ly without  resort  to  calculations  of  grammes  of  carbon,  nitrogen,  etc. 
A  criticism  has  lately  reached  me  from  the  inmates  of  a  large 
girls'  college,  where  the  diet  has  for  some  time  been   experimentally 


FORCE   PRODUCTION.     ENERGY   FROM   FOOD. 


II 


regulated  by  an  expert  in  such  matters,  that  "  if  one  half  the  time 
were  bestowed  upon  properly  serving  and  selecting  the  food  that  is 
given  to  computation  of  its  force-producing  value,  the  girls  would 
have  very  much  better  appetites  and  digestion."  On  the  other  hand, 
it  is  easy  to  err  if  the  dictates  of  hunger  and  capriciousness  of  appe- 
tite are  allowed  to  wholly  control  diet.  In  the  lower  animals  the 
instincts  which  these  factors  develop  are  very  much  safer  guides  than 
in  the  case  of  man. 

Nevertheless,  the  knowledge  derived  from  experiments  of  the 
kind  under  discussion  is  certainly  useful  and  instructive,  when  allow- 
ance is  made  for  its  relative  value  by  taking  into  consideration  the 
wide  range  of  circumstances  that  will  modify  its  application  which 
occur  in  the  organisation  of  different  individuals,  in  their  varying 
capacity  for  work,  and  in  the  condition  of  their  external  surroundings. 
With  this  word  of  explanation  the  following  tables  from  different  au- 
thors are  reproduced.  It  will  be  observed  that  there  are  some  few 
discrepancies  among  them,  but  the  cause  has  been  explained  above. 

The  following  table  of  analyses,  given  by  Captain  C.  E.  Woodruff, 
M.  D.,  Assistant  Surgeon,  United  States  Army,  differs  in  some  details 
from  the  preceding  table  by  Parkes,  (p.  6),  and  adds  several  in- 
gredients together  with  the  calories. 

Percentage  Composition  of  Edible  Portions  of  Garrison  Ration. 


Bacon,  fat 

Beans 

Pork,  salt  and  fat 

Sugar,  ground 

Sugar,  brown  issue 

Flour 

Beef 

Potatoes 

Onions 

Oatmeal 

Cornmeal 

Canned  apples 

Dried  apples 

Tapioca  or  cornstarch . . . 

Butter 

Syrup 

Lard 

Rice 

Canned  corn 

Canned  tomatoes 

Macaroni  and  vermicelli. 

Milk,  fresh 

Milk,  condensed 

Peas 

Raisins 

Cheese . , 

Prunes  

Cabbage 


Water. 


20 

12 

12 

2 

3 
12 

55-0 
78.9 
87.6 

7.6 
15-0 
83.2 
25.0 

2.0 
10.5 

43-7 
12.0 
12.4 
81.3 
96.0 

13. 1 
14. 1 
25.0 
12.3 
40.0 
350 
30.0 
92.0 


Protein. 


8.00 

23.10 

0.90 


11.00 
17.10 
2.10 
1.4 
15-10 
9.20 
0.20 
0.90 

1. 00 

0.60 

7-4 

2.80 

0.80 

9.00 

0.843 

17.00 

26.70 

0.40 

33.00 

2.50 

2.10 


Fats. 


69-5 
2.0 

82.8 


I.O 

27.0 

O.I 

0.3 

7-1 
3-8 
0.4 

1.8 

85.0 

83-4 
0.4 
I.I 
0.4 

0.3 
0.802 

II. o 

1-7 
22.0 
*o!6 


Carbo- 

hydrates. 

Salts. 

2.5 

59-2 

3-1 

4.2 

97.8 

0.2 

96.5 

0-5 

74-9 

0-5 

.... 

0.9 

17.9 

1.0 

10. 1 

0.6 

68.2 

2.0 

70.6 

1.4 

15-9 

0.3 

71-5 

1.4 

97.8 

0.2 

0.5 

3-0 

55-0 

2-3 

4.0 

79-4 

0.4 

13.2 

0.6 

2.5 

0.3 

76.8 

0.8 

1.069 

0.164 

44.00 

3-0 

56.40 

2.9 

24.00 

0.6 

5.00 

50 

12.0 

0.6 

5-5 

I.I 

Energy, 
calones 
•per  lb. 

3.080 
I.615 
3,510' 
1,820 

1.795 
1,644 
1,460 

375 
225 
1,850 
1,645 
315 
1,418 
1,820 

3-615 
1,023 
3,570 
1,630 

345 

80 

1,406 

418 
1,595 
1,565 

440 
1,600 

140 

155 


12 


FOODS  AND  FOOD  PREPARATIONS. 


Ham 

Apricots,  canned. 

Barley 

Chocolate 

Sausage 

Oysters 

Salmon,  canned.. 

Crabs 

Crackers 


Water. 


41-5 
50.0 

12.0 

41.2 
87.1 
63.6 


Protein. 


16.7 

2.00 
13-00 
20.00 
13-80 
6.00 
21.60 
15-0 
10.3 


Fats. 


39-1 

2.7 
50.0 
42.8 

1.2 

13-4 
I.O 
9.4 


Carbo- 
hydrates. 


30.0 
76.0 

10. 0 

3-7 
70.5 


Salts. 


2.7 
0.6 
3-0 
4.0 
2.2 
2.0 
1.4 


Enerf^, 
calories 
per  lb. 


1,960 

460 

1,800 

2,650 

2,065 

230 

965 

526 

1,900 


Church  furnishes  the  following  table  showing  the  number  of  tons 
which  it  is  calculated  could  be  raised  through  the  height  of  one  foot 
by  the  complete  combustion  of  a  single  pound  of  each  kind  of  food. 
In  the  body  only  about  a  fifth  of  this  energy  would  develop  work,  the 
rest  going  into  heat  production : 

I  pound  beef  fat  raises  5,649  tons  i  foot  high. 


oatmeal 

"      2,439     " 

gelatin 

'      2,270     "         " 

lean  beef 

885     " 

potatoes 

618     " 

milk 

390     " 

ground  rice 

'      2,330     " 

Standards  for  Daily  Dietaries. 

(Compiled  by  Atwater.) 

Weights  of  nutrients  and  calories  of  energy  (heat  units)  in  nutrients  required  in  food 

per  day. 


I.  Children  to  a  year  and  a  half. 


2.  Children  of  two  to  six  years  , 


3.  Children  of  six  to  fifteen  years. 


10. 
ir. 
12. 

13- 
14. 

15- 
16. 

17- 


Aged  women 

Aged  man 

Women  at  moderate  work  (Voit). . 

Man  at  moderate  work  (Voit) 

Man  at  hard  work  (Voit) 

Man  with  moderate  exercise  (Play- 
fair)  

Active  labor  (Playfair) 

Hard  labor  (Playfair) 

Women  with  light  exercise  (At- 
water)   

Man  with  light  exercise  (Atwater). 

Man  at  moderate  work  (Atwater). . 

Man  at  hard  work  (Atwater) 

Man  at  moderate  work  (Moleschott) 

Man  at  moderate  work  (Wolff).. . . 


NUTRIENTS. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total. 

Grammes. 

Grammes. 

Grammes. 

Grtns. 

28 

37 

75 

140 

(20-36) 

(30-45) 

(60-90) 

55 

40 

200 

295 

(36-70) 

(35-48) 

(100-250) 

75 

43 

325 

443 

(70-80) 

(37-50) 

(250-400) 

80 

50 

260 

390 

100 

68 

350 

518 

92 

44 

400 

536 

118 

56 

500 

674 

145 

100 

450 

695 

119 

51 

531 

701 

156 

71 

568 

795 

185 

71 

568 

824 

80 

80 

3C0 

460 

100 

100 

360 

460 

125 

125 

450 

700 

150 

150 

500 

800 

130 

40 

550 

720    . 

120 

35 

540 

695 

Potential 
energy. 


Calories. 
767 

1,418 

2,041 

1.859 

2,477 
2,426 

3,055 
3,370 

3,139 
3,629 
3,748 

2,300 
2,820 
3,520 
4,060 
3,160 
3,032 


FORCE   PRODUCTION.     ENERGY   FROM    FOOD, 


13 


Landois  and  Stirling  give  the  following  table,  which  differs  some- 
what from  the  foregoing  in  the  relative  proportion  of  fats  and 
starches.  An  adult  doing  a  moderate  amount  of  work  takes  in  as 
food  per  diem — 


C. 

H. 

N. 

0. 

120  grammes  albumin,  containing. . . . 

90        "         fats,  containing 

330        "         starches,  containing 

64.18 

70.20 

146.82 

8.60 
10.26 
20.33 

18.88 

28.34 

9-54 

162.85 

281.20 

39-19 

18.88 

200.73 

Add     744.11  grammes  O.  from  the  air  by  respiration. 
"     2,818.00        "  H»0. 

"         32.00        "         inorganic  compounds  (salts). 

The  whole  is  equal  to  three  kilogrammes  and  a  half  (seven 
pounds),  i.  e.,  about  a  twentieth  of  the  body  weight,  so  that  about 
six  per  cent  of  the  water,  about  six  per  cent  of  the  fat,  about  one 
per  cent  of  the  albumin,  and  about  0.4  per  cent  of  the  salts  of  the 
body  are  daily  transformed  within  the  organism. 

An  adult  doing  a  moderate  amount  of  work  gives  off  in  grammes : 


o. 


By  respiration . , 
By  perspiration 

By  urine 

By  faeces , 


Water. 

C. 

H. 

N. 

660 

1,700 

128 

248.8 

2.6 

9.8 

20.0 

3-3 
3-0 

? 

15^8 
3-0 

2,818 

281.2 

6.3 

18.8 

651-15 
7.2 

II. I 
12.0 


681.45 


The  following  table  is  a  fair  average  work  ration  in  round  num- 
bers, based  on  such  data  as  those  in  the  foregoing  tables : 

Estimated  Work  Ration,  Maximum  and  Minimum. 

(Mrs.  E.  H.  Richards.)  For  one  day. 

Proteid,  grammes \    ^ 

•c  *  \  125 

r  at,  grammes -j     /t 

Carbohydrates,  grammes ]  ^lo 

Calories I  3.500 

I  3.000 

About  thirty  grammes  of  salts  should  be  added  to  this  (Landois). 
The  bare  subsistence  ration  is  much  less,  as  follows : 

Estimated  Life  Ration. 
(Mrs.  E.  H.  Richards.)  For  one  day, 

Proteid,  grammes 75 

Fat,  grammes 40 

Carbohydrates,  grammes 325 

Calories 2,000 


14 


FOODS  AND   FOOD   PREPARATIONS. 


Prof.  Egleston's  standard  of  nutrition  is  high.  He  places  the 
daily  allowance  of  nutritive  material  at  700  grammes,  divided  as  fol- 
lows: Carbohydrates,  400  grammes;  fats,  150  grammes;  proteid,  150 
grammes;  yielding  in  all,  3,650  calories. 

The  average  percentage  of  the  different  food  classes  needed  to 
sustain  a  man  in  perfect  health  is  thus  given  in  the  Kensington  Mu- 
seum Handbook  on  Food  : 

Percentage. 

Water 81.5 

Albuminoids  or  flesh  formers 3.9 

Starches  and  sugars 10.6 

Fat 3.0 

Salt  (NaCl) 0.7 

Phosphates,  potash  salts,  etc 0.3 

An  Ideal  Ration  with  Solid  Food. 
(Mrs.  E.  H.  Richards.) 


AMOUNT. 

PROTEID. 

FAT. 

CARBOHYDRATES. 

Material. 

Grms. 

Oz. 

Grms. 

Oz. 

Grms. 

Oz. 

Grms. 

Oz. 

Calories. 

Bread 

453-6 

226.8 

226.8 

28.3 

"3-4 

453-6 

28.3 

14.17 

16 

8 
8 
I 

4 
16 

I 

31.75 
34.02 

12.52 
6  60 

3-63 
18  14 

0.14 

1. 12 
1.20 
0.44 
0.23 
0.13 
0.64 

2.26 

11-34 
2.04 
7-50 
4.42 

18.14 

12.27 

0.08 
0.40 
0  07 
0.26 
0.16 
0.64 

257.28 

9.60 

4.88 
90.72 
27.36 

9.04 

0-34 
0.17 
3-20 
0.96 

1,206.82 

Meat 

243 • 72 

Oysters 

Breakfast  cocoa. 
Milk 

70.01 
135-42 

75-55 
613.21 
112. 17 
118.62 

Broth 

Sufifar 

Butter 

Total 

106.80 

57-97 

.... 

389.84 

2,575-52 

It  will  be  observed  that  the  totals  are  somewhat  less  in  this  diet 
than  those  of  the  preceding  table,  which  was  designed  for  a  working 
man,  who  is  developing  more  calories. 

'Table  of  Energy  estimated  in  Foot  Tons  instead  of  Calories  (Yeo). 
Energy  developed  by  one  ounce  of  the  following  foods  when  oxidised  in  the  body. 


Food  Stuff. 


Beef  (best  quality),  uncooked 

Meat  (served  to  soldiers),  uncooked 

Beef  (fattened),  uncooked 

Meat,  cooked 

Corned  beef  (Chicago) 

Salt  beef 

Salt  pork 

Fat  pork 

Dried  bacon 

Smoked  ham 

Whitefish 

Poultry 

Bread 

Wheat  flour 


With  usual  per- 

One ounce 

centage  of  water. 

water-free. 

Foot  tons. 

Foot  tons. 

48-5 

199 

57-8 

243 

96.0 

280 

102.6 

240 

124.0 

217 

52.0 

138 

71.6 

166 

202.0 

336 

292.3 

346 

179-6 

267 

44-3 

209 

50.7 

204 

87.5 

147 

123.6 

146 

FORCE-PRODUCING  VALUE  OF  FOODS. 


15 


Food  Stuff. 


Biscuit , 

Rice 

Oatmeal 

Maize , 

Macaroni 

Millet 

Arrowroot 

Peas  (dried) 

Potatoes 

Carrots 

Cabbage 

Butter 

Eggs 

Cheese 

Milk  (cow's),  new . . 

Cream 

Skimmed  milk 

Sugar 

Pemmican 

Ale  (Bass's  bottled) 
Stout  (Guinness) . . . 


With  usual  per- 

One ounce 

centage  of  water. 

water-free. 

Foot  tons. 

Foot  tons. 

173-3 

189 

126.5 

141 

130.0 

154 

132.0 

160 

122.7 

146 

125-9 

149 

116. 4 

138 

118. 9 

151 

33-0 

141 

14-3 

137 

13.0 

158 

344-5 

367 

67-3 

265 

149.9 

245 

26.9 

225 

109.2 

365 

20.4 

181 

126.4 

128 

270.1 

293 

30.0 

260 

41-5 

360 

FORCE-PRODUCING  VALUE   OF  THE  DIFFERENT 
CLASSES  OF  FOODS. 

I.  Water. — Estimated  as  a  force  producer  within  the  body,  water 
may  be  said  to  have  comparatively  little  value.  Much  of  the  water 
which  is  either  drunk  or  ingested  in  combination  with  foods  passes 
through  the  body  unchanged,  and  is  eliminated  from  one  or  more  of 
the  excreting  surfaces ;  but  some  of  it  is  undoubtedly  altered  or  split 
up  into  elements  which  unite  with  other  compounds.  The  nature  of 
these  processes  is  obscure,  and  as  yet  very  little  understood.  It  is 
believed  also  that  a  certain  quantity  of  water  is  produced  in  the  body 
by  the  union  of  oxygen  and  hydrogen  which  occurs  incident  to  other 
chemical  change,  or  by  the  liberation  of  water  from  more  complex 
molecules.  Water  is  entitled  to  rank  as  a  food  because  it  enters 
into  the  structural  composition  of  all  the  tissues  of  the  body,  and, 
in  fact,  constitutes  rather  more  than  two  thirds  (70  per  cent)  of 
the  entire  body  weight.  Its  importance  is  readily  appreciated  after 
it  has  been  withheld  from  the  diet  for  a  short  time,  when  striking 
physical  and  physiological  alterations  in  the  functions  of  the  body 
occur. 

Yeo  says  that,  "  assuming  the  water-free  food  to  be  23  ounces, 
and  a  man's  weight  to  be  150  pounds,  each  pound  weight  of  the 
body  receives  in  twenty-four  hours  0.15  ounce,  or  the  whole  body 
receives  nearly  a  hundredth  part  of  its  own  weight.  But  ordi- 
nary solid  food  contains  usually  between  50  and  60  per  cent  of 
water;  and  if  we  add  this  to  the  water-free  solids,  the  total  daily 


l6  FOODS  AND  FOOD  PREPARATIONS. 

amount  of  so-called  dry  food  (exclusive  of  liquids)  is  about  48  to 
60  ounces.  But  from  50  to  80  ounces  of  water  in  the  liquid  form 
is  usually  taken  in  addition,  and  this  would  make  the  total  supply 
of  water  equal  70  to  90  ounces,  or  half  an  ounce  for  each  pound  of 
body  weight." 

II.  Salts. — The  salts  have  practically  no  force  producing  power, 
but  they  are  concerned  in  tissue  formation  to  some  extent,  especially 
in  the  bones  and  teeth,  where  the  lime  and  magnesium  compounds 
are  the  most  fixed  of  any  in  the  body.  Some  of  the  compounds  of 
sulphur  and  phosphorus  which  occur  in  meat  and  bran  are  undoubt- 
edly associated  with  the  development  of  energy  in  the  body,  but  the 
salts  are  already  saturated  and  stable,  and,  although  their  functions 
as  laboratory  agents  within  the  body  are  numerous,  they  may  be  left 
out  of  calculations  of  force-producing  foods. 

III.  Proteids,  Carbohydrates,  and  Fats. — It  is  easy  to  de- 
termine with  accuracy  the  force  value  of  a  pound  of  albumin  by 
chemical  analysis,  but  it  does  not  follow  from  this  that  the  energy 
contained  in  it  will  all  be  developed  in  the  body  at  exactly  the  right 
time  or  even  within  a  sufficiently  short  period  to  enable  the  system 
to  utilise  it  completely.  Von  Pettenkofer  and  Voit  have  shown  that 
during  the  performance  of  hard  labour  the  consumption  of  albumin 
remains  practically  the  same  as  during  rest,  whereas  fully  three  and 
a  half  times  as  much  fat  is  consumed  and  the  amount  of  carbohy- 
drates remains  unaltered,  the  diet  being  abundant  when  due  allow- 
ance is  made  for  the  influence  of  varying  external  conditions.  Hence 
for  hard  labour,  beef  should  not  be  increased  so  much  as  fats,  pork, 
butter,  oil,  etc.  The  latter  are  good  heat  producers,  and  good  foods 
for  both  nerves  and  muscles.  The  daily  quantity  of  solid  food  con- 
sumed by  an  adult  male  at  ordinary  work  will  range  between  50  and 
60  ounces,  and  that  of  water  drunk  is  about  the  same.  The  require- 
ments of  severe  labour,  if  continued,  exceed  this  range,  so  that  as 
much  as  75  ounces  of  solid  food  may  become  necessary,  and  this  should 
be  mainly  in  the  form  of  albuminates  and  fats.  The  standard  diet 
for  twenty-four  hours  for  a  healthy  adult  male  at  ordinary  work 
should  contain,  in  round  numbers,  20  grammes  of  nitrogen  (con- 
tained in  120  grammes  of  proteid)  and  320  grammes  of  carbon,  a 
proportion  of  i  to  16,  but,  because  the  food  is  best  taken  in  the  form 
of  a  mixed  diet,  the  proportion  may  be  stated  as  one  part  of  nitro- 
genous or  animal  food  to  three  or  three  and  one  half  of  non-nitro- 
genous or  vegetable  food.  Ordinary  albuminous  food  yields,  on  the 
average,  about  16  per  cent  of  nitrogen. 

For  an  adult  male  the  average  consumption  of  nitrogen  being  20 
grammes  per  diem,  the  ordinary  allowance  for  daily  variation  does 
not  exceed  3  grammes  on  either  side  of  this  standard.  For  a  man 
of  average  weight — that  is,  67  kilogrammes — the  daily  allowance  of 


FORCE-PRODUCING  VALUE  OF  FOODS. 


17 


food  ranges  from  6  to  9  grains  of  carbon,  and  0.25  to  0.36  grain  of 
nitrogen  per  kilogramme  of  body  weight.  Those  elementary  foods 
which  approach  most  nearly  in  composition  the  economical  propor- 
tion of  nitrogenous  to  non-nitrogenous  material  are  cow's  milk  and 
wheat  flour.  In  the  former  this  proportion  is  one  to  three,  in  the 
latter  one  to  four  and  a  half. 

The  question  of  the  nutritive  value  of  any  fixed  diet  cannot  be 
solely  estimated  from  variations  in  the  body  weight,  for  the  loss  of 
water  or  of  albumin  may  increase  while  fat  is  stored  up.  Neither 
can  the  quantity  of  food  eaten  be  relied  upon  for  this  purpose,  for 
from  habit  one  man  may  eat  more  than  another  while  doing  the  same 
work,  and  may  eat  more  than  he  needs.  Nor  is  it  possible  to  deter- 
mine from  the  various  excreta  alone  whether  the  body  has  had  a 
suitable  quantity  of  nourishment,  for  they  are  too  constantly  chang- 
ing, and  "life  will  soon  become  extinct  if  the  nutriment  given  be 
measured  by  the  metabolism  of  starvation  "  (Bauer). 

A  man  in  perfect  health  might  easily  lose  weight  upon  the  iden- 
tical diet  which  would  enable  an  emaciated  and  feeble  invalid  to  gain 
flesh.  In  convalescence  from  typhoid  fever,  for  example,  one  often 
sees  evidence  of  a  daily  gain  in  weight  while  the  quantity  of  food  is 
still  far  below  that  necessary  to  support  a  healthy  man  in  vigour.  The 
needs  of  the  organism  at  any  particular  time  must,  therefore,  be 
taken  into  account  as  well  as  the  strength  of  the  digestive  organs  in 
prescribing  the  quantity  of  food  consumed.  In  making  calculations 
for  the  quantity  of  food  required  by  large  numbers  of  persons  under 
any  conditions,  somewhat  more  than  the  averages  above  stated 
should  be  always  included  in  order  to  make  allowance  for  variations 
in  absorption  and  assimilation  of  the  food  by  different  individuals. 
(See  Quantity  of  Food  Required.) 

The  carbohydrates  are  not  as  available  for  the  repair  and  growth 
of  the  tissues  as  the  fats,  but  by  their  oxidation  they  save  tissue 
waste,  and  furnish  both  heat  and  muscle  force. 

Bauer  says:  "  The  easy  metabolism  of  the  carbohydrates  in  the 
body  must  not  be  regarded  as  depending  on  their  great  affinity  for 
oxygen ;  its  cause  is  to  be  sought  far  more  in  the  properties  of  the 
animal  tissues.  .  .  .  The  action  of  the  carbohydrates  agrees  in 
many  respects  with  that  of  fat,  since  they  are  in  like  manner  capa- 
ble of  protecting  from  metabolism  a  certain  amount  of  the  cir- 
culating albumin  and  of  assisting  its  transformation  into  organic 
albumin." 

But  the  destruction  of  carbohydrates  in  the  body  is  very  com- 
plete, even  when  eaten  in  excess,  and  herein  they  differ  from  the 
fats,  "an  excess  of  which  in  the  food  invariably  produces  an  acces- 
sion of  fat."  From  these  and  other  statements  made  by  Bauer  he 
argues  that  probably  the  carbohydrates  do  not  directly  form  fat  in 
4 


1 8  FOODS  AND   FOOD   PREPARATIONS, 

the  body,  but  their  well-known  fattening  action  is,  when  eaten  with 
albumin  and  fat,  to  spare  the  consumption  of  these  latter  substances, 
which  are  then  converted  into  tissue  fat. 

When  a  muscle  contracts  it  is  not  the  muscle  tissue  itself  which  is 
consumed,  but  its  supply  of  glycogen.  The  candle  wick  is  but  very 
slowly  burned  so  long  as  its  supply  of  tallow  does  not  fail,  and  so 
the  muscle  is  spared  while  the  carbohydrates  furnish  force.  When  a 
muscle  is  much  used  it  increases  in  size,  and  needs  more  nitrogen  to 
build  new  substance. 

Albumin  burned  in  oxygen  outside  of  the  body  is  very  completely 
oxidised,  but  after  oxidation  in  the  body,  about  one  third  of  its  sub- 
stance is  excreted,  imperfectly  consumed,  as  urea.  On  the  other 
hand,  the  consumption  of  some  carbohydrates,  such  as  alcohol  and 
sugar,  appears  as  complete  within  the  body  as  it  may  be  outside  of 
it,  and  the  amount  of  energy  actually  developed  is  identical  with  that 
which  may  be  theoretically  calculated. 

The  statement  is  sometimes  made  that  the  compounds  of  carbon 
and  hydrogen  are  slowly  oxidised,  and  give  a  more  continuous  yield 
of  energy  than  nitrogenous  compounds,  but  with  less  powerful  indi- 
vidual discharges.  In  other  words,  they  are  said  to  be  good  "  main- 
tainers  of  energy."  There  are,  however,  many  exceptions  to  this, 
like  naphtha  and  benzine,  and  even  the  food  alcohol. 

The  proportion  of  nitrogenous  or  proteid  compounds  required  is 
greatest  where  growth  is  active.  Nitrogenous  substances  possess 
high  potential  and  explosive  energy,  as  illustrated  by  nitroglycerin 
and  fulminating  powder.  Proteids  are  always  present  where  the 
phenomena  of  life  are  exhibited,  and  bear  a  direct  relation  to  their 
activity. 

STIMULATING    FOODS. 

In  the  broadest  sense  all  food  is  stimulating  to  the  functional  ac- 
tivities of  the  body ;  but  when  the  digestive  and  assimilative  powers 
are  lowered,  less  variety  and  less  quantity  of  food  can  be  tolerated, 
and  foods  that  in  health  are  never  needed  may  become  necessities; 
such  foods,  for  example,  are  cod-liver  oil  and  the  various  prepara- 
tions of  meat,  such  as  albumoses  or  peptones,  meat  juice,  etc. 

Certain  food  substances  have  a  distinctly  stimulating  action  at 
all  times.  The  various  condiments  possess  a  local  action  of  this 
kind  upon  the  alimentary  organs,  but  not  a  general  or  systemic  ac- 
tion. The  latter  stimulation,  manifested  especially  upon  the  nerve- 
muscular  apparatus,  is  derived  from  such  substances  as  strong  beef 
extracts,  coffee,  tea,  and  alcohol,  all  of  which  at  times  are  of  great 
service  in  the  dietetic  treatment  of  disease. 


ECONOMIC  VALUE  OF  FOOD.  lO 

ECONOMIC  VALUE  OF  FOOD. 

It  is  not  within  the  scope  of  this  work  to  discuss  the  details  of 
the  economic  value  of  foods,  but  brief  reference  to  one  or  two  facts 
will  emphasize  the  importance  of  this  topic. 

It  is  estimated  that  the  actual  annual  cost  of  food  production  in 
the  United  States  is  at  least  three  billion  dollars,  and  the  cost  of 
production  must  be  doubled  in  estimating  the  price  paid  by  the  con- 
sumer. 

Naturally,  many  attempts  have  been  made  to  tabulate  the  cost  of 
feeding  large  bodies  of  men  employed  by  contract,  or  patients  in 
hospitals  and  institutions.  Some  of  these  studies  have  been  con- 
ducted with  great  care,  but  on  a  comparatively  small  scale,  as  in  the 
case  of  the  economic  diets  of  the  French  factory  operatives  in  Mas- 
sachusetts, the  penny  dinners  furnished  to  London  school  children, 
and  the  researches  made  by  Mrs.  Richards  and  Miss  Talbot  upon 
pupils  at  the  University  of  Chicago. 

Calculations  upon  a  much  larger  scale  are  available  as  a  basis 
for  the  supply  of  armies  and  navies.  Further  consideration  of 
this  topic  will  be  found  in  the  section  upon  Diet  for  the  Army  and 
Navy  (page  680). 

The  economic  value  of  food  is  by  no  means  to  be  estimated  ex- 
clusively from  its  weight,  and,  as  suggested  by  Williams,  a  pound  of 
biscuit  may  contain  more  actual  force-producing  material  than  a 
pound  of  beefsteak,  and  yet  the  body  may  be  able  to  assimilate  more 
of  the  beefsteak  and  derive  more  energy  therefrom ;  and  it  is  the 
chemical  processes  of  Nature  which  convert  such  substances  as  grass, 
which  are  not  assimilable  by  the  human  organism,  into  the  flesh  of 
the  ox,  which  is  readily  digested  by  man. 

It  is  economical  for  contractors  employing  large  bodies  of  men  in 
manual  labour  to  see  that  they  are  well  fed,  for  much  more  work 
proportionately  will  then  be  got  from  them. 

Carbohydrates  check  albuminous  waste,  and,  like  fats,  yield  both 
heat  and  mechanical  work ;  hence  good  bread,  sugar,  and  vegetables 
are  all  economical  foods  for  the  labourer.  Unlike  the  other  classes 
of  foods,  however,  they  do  not  produce  brawn,  and  do  not  enter  into 
the  actual  structure  of  the  tissues  to  any  great  extent,  although  the 
carbohydrates  may  be  found  existing  as  glycogen  in  some  of  the 
tissues,  like  the  muscles  and  liver.  In  general,  they  seem  to  be 
more  easily  metabolised  than  fats  or  proteids. 

The  following  tables  give  a  fair  conception  of  the  economical 
value  of  common  foods  in  relation  to  their  waste  residue  and  ca- 
pacity for  producing  work : 

Note. — An  admirable  Digest  of  Metabolism  Experiments  has  lately  been  pre- 
pared by  W.  O.  Atwater  and  C.  F.  Langworthy,  under  the  supervision  of  A.  C.  True, 
Director  of  the  Office  of  Experiment  Stations,  and  issued  as  Bulletin  No.  45  of  the 
United  States  Department  of  Agriculture,  1897. 


20 


FOODS  AND  FOOD  PREPARATIONS, 


The  Relative  Value  of  Foods  (Scammell). 
(The  figures  represent  percentages.) 


Articles. 


Wheat 

Barley , 

Oats 

Northern  com . 
Southern  com.. 
Buckwheat . . . , 

Rye 

Beans 

Peas 

Lentils 

Rice 

Potatoes 

Sweet  potatoes. 

Parsnips 

Turnips 

Carrots. 

Cabbage 

Cauliflower . . . , 
Cucumbers  . . . . 
Milk  of  cow. . . . 
Milk,  human.. . 

Veal 

Beef 

Lamb , 

Mutton 

Pork 

Chicken 

Codfish 

Trout 

Smelt 

Salmon 

Eels 

Herring 

Halibut 

Oysters 

Clam 

Lobster 

Eggs  (white  of), 
Eggs  (yolk  of). . 

Butter 

Artichoke 

Asparagus 

Bacon 

Carp 

Cheese 

Cherries 

Chocolate 

Cream 

Currants 

Dates  (fresh) . . . 

Figs 

Ham 

Horseradish  . . . 

Kidney 

Lard 

Liver 


As  mate- 
rial for  the 
muscles. 


As  heat 
givers. 


14.6 
12.8 
17.0 
12.3 

34-6 
8.6 
6.5 

24 

23 

26 

5 
I 


1.2 
3.6 
0.1 
50 
3.0 

17-7 
19.0 
19.6 
21.0 

17-5 
21.6 
16.5 
16.9 
17.0 
20.0 
17.0 
18.0 
18.0 
12.6 
12.0 
14.0 
13.0 


1.9 
0.6 

8.4 

18.0 

30.8 

0.6 

8.8 

3-5 
0.9 

5-0 
35-0 

0.1 
21.2 

26.3 


66.4 
52.1 
50.8 
67.5 
39-2 
53-0 
75-2 
40.0 
41.0 
39-0 
82.0 
15.8 
21.8 

14-5 

4.0 
12.2 

6.2 

4,6 

1-7 
8.0 
7.0 

14.3 
14.0 

14-3 

14.0 

16.0 

1.9 

i.o 

0.8 

Very  little 

Some  fat 


Very  little 


29.8 

100. o 

19.0 

5-4 
62.5 

0.8 
28.0 
21.0 
88.0 

4.5 
6.8 

73-7 

57-9 

32.0 

4.8 

0.9 

100. o 

3-9 


As  food  for 
the  brain 
and  nerv- 
ous system. 


1.6 
4.2 
3-0 
I.I 

4-1 

1.8 


2.5 
1-5 
0.5 
0.9 
2.9 
1.0 

0.5 
1.0 
0.8 
1.0 

0.5 
1.0 

0.5 
2.3 
2.0 
2.2 
2.0 
2.2 
2.8 
2.5 
4-3 

5  or  6 

6  or  7 

3  or  4 

4  or  5 
3  or  4 

0.2 
2  or  3 

5  or  6 
2.8  • 
2.0 

"I'.k 
0.4 
0.5 
2.9 

4-7 
1.0 

1.8 

0.3 


Water. 


14.0 

3- 

14.0 

16. 

13.6 

16. 

14.0 

5- 

14.0 

8. 

14.2 

22. 

13.5 

4- 

14.8 

17- 

14. 1 

19. 

14.0 

19. 

9.0 

3- 

74.8 

7. 

67.5 

6. 

79.4 

3- 

90.4 

3- 

82.5 

3. 

91-3 

0. 

90. 0 

0. 

97.1 

0. 

86.0 

89-5 

65.7 

65.0 

63-9 

63.0 

64-3 

73-7 

80.0 

78.0 

750 

74.0 

75-0 

75.0 

74.0 

87.2 

79.0 

84.2 

51-3 

76.6 

0.' 

93-6 

28.6 

78.3 

36.5 

76.3 

I. 

i..^ 

92.0 

81.3 

10.  • 

24.0 

2.' 

18.7 

I5-C 

28.6 

78.2 

16. c 

76.5 

68!6 

.  •  • 

ECONOMIC  VALUE   OF   FOOD. 


21 


Articles. 


Onions 

Pearl  barley 

Pears 

Pigeon 

Prunes 

Radishes . . . 

Suet 

Venison. . . . 
Vermicelli . . 
Whey 


As  mate 

rial  for  the 

muscles. 


0.5 

4-7 


o, 

23. 
3. 


20.4 

47-5 


As  heat 
givers. 


5-2 

78.0 

9.6 

1.9 

78.6 

7-4 

100. o 

8.0 

38.0 

4.6 


As  food  for 
the  brain 
and  nerv- 
ous system. 


0.5 
0.2 

2-7 

4-5 
i.o 

2!8 

1-7 
0.7 


Water. 


93- 
9- 
86. 
72. 
13- 


68. 
12. 
94. 


Waste. 


8 

"5  7 

4  3 

4 

o 

I  I 

8  '.'. 

8 

7 


Atkinson's  Table  of  Digestibility  of  Nutrients  of  Food  Materials. 


In  the  Food  Materials  Below 


Meat  and  fish . . . . 

Eggs 

Milk 

Butter 

Oleomargarine. . . . 

Wheat  bread 

Com  (maize)  meal 

Rice 

Peas 

Potatoes 

Beets 


OF  THE   TOTAL   AMOUNTS  OF   PROTEIN,   FATS,   AND 

CARBOHYDRATES   THE   FOLLOWING   PERCENTAGES 

WERE   DIGESTED. 


Protein. 

Fats. 

Carbohydrates. 

Practically  all 

79  to  92 
96 

88  to  100 

93  to  98 
98 
96 

? 

81  to  100 

? 

99 

89 

? 

97 

84 

? 

99 

86 

? 

96 

74 

? 

92 

72 

? 

82 

Percentage  of  Nutrition  in  Various  Articles  of  Food  (Moss). 


Raw  cucumbers 2 

Raw  melons 3 

Boiled  turnips 4-J 

Milk 7 

Cabbage 7^ 

Currants 10 

Whipped  eggs 13 

Beets 14 

Apples 16 

Peaches 20 

Boiled  codfish 21 

Broiled  venison 22 

Potatoes 22^ 

Fried  veal 24 

Roast  poultry 26 


Raw  beef. 26 

Raw  grapes 27 

Raw  prunes 29 

Boiled  mutton ^  . .   30 

Oatmeal  porridge 75 

Rye  bread 79 

Boiled  beans 87 

Boiled  rice 88 

Barley  bread 88 

Wheat  bread 90 

Baked  corn  bread 91 

Boiled  barley 92 

Butter 93 

Boiled  peas 93 

Raw  oil 96 


22 


FOODS  AND  FOOD  PREPARATIONS. 


Atkinson  s  Table  for  Nutrients  and  Potential  Energy  in  Dietaries  of 
Different  People. 


European  and  Japanese  dietaries  : 

Sewing  girl,  London — wages   93  cents 

(3J.  9</.)  per  week 

Factory  girl,  Leipsic,  Germany — wages 

$1.21  per  week 

Underfed  labourers,  Lombardy,  Italy — 

diet  mostly  vegetable 

Trappist   monk   in   cloister,  very  little 

exercise — vegetable  diet 

Miners  at  severe  work,  Germany 

Brickmakers  (Italians  at  contract  work), 

Munich 

Brewery  labourer,  Munich,  very  severe 

work,  exceptional  diet 

German  soldiers,  peace  footing 

German  soldiers,  war  footing 

German  soldiers,  Franco-German  War — 

extraordinary  ration 

Other  factory  operatives,  mechanics,  etc., 

Massachusetts 

Glass  blowers,  East  Cambridge 

Private  well-to-do  family : 

Food  purchased 

Food  eaten 

College  students  from  Northern  and  East- 
ern States — boarding : 

Food  purchased 

Food  eaten 

Club,  two  dietaries  of  the  same  club  : 

Food  purchased 

Food  eaten 

College  football  team 

Teamsters,  marble  workers,  etc.,  with  hard 

work,  Boston,  Mass 

Brickmakers,  Massachusetts 

United»States  Army  ration 

United  States  Navy  ration 


NUTRIENTS. 

Potential 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total. 

energy  of 
nutrients. 

Grnts, 

Grnts. 

Grtns. 

Grnts. 

Calories. 

53 

33 

316 

402 

1,820 

52 

53 

301 

406 

I:940 

82 

40 

362 

484 

2,192 

68 
133 

II 
113 

469 
634 

548 
&80 

2,304 

4.195 

187 

117 

675 

959 

4,641 

223 
114 
134 

"3 

49 

58 

909 

480 
489 

1.245 
633 
681 

5,692 
2,798 
3.093 

157 

285 

331 

773 

4,652 

127 
95 

186 
132 

531 
481 

844 
708 

4,428 
3,590 

129 

128 

183 
177 

467 
466 

779 
771 

4,146 

4,082 

161 

138 

204 
184 

680 
622 

1.045 

944 

5,345 
4,827 

"5 
104 
181 

163 
136 
292 

480 
421 

557 

738 

661 

1,030 

3,874 
3,417 
5,742 

254 
180 
120 
143 

363 
365 
161 

184 

826 
1,150 

454 
520 

1,443 
1,695 

735 
847 

7,804 

8,84s 

3,851 
4,998 

NUTRITION.    ANIMAL  AND  VEGETABLE 
COMPARED. 


FOODS 


The  study  of  nutrition,  or  the  problem  of  tracing  the  food  prod- 
ucts, after  absorption  from  the  alimentary  canal,  through  the  various 
changes  which  they  undergo  prior  to  elimination  in  the  compara- 
tively simple  forms  of  waste  matter — namely,  water,  urea,  and  CO, — 
has  long  baffled  the  science  of  physiological  chemistry.  There  are, 
however,  general  principles  that  are  established  both  by  analysis  and 
clinical  observation  which  concern  the  effect  upon  the  system  of  these 
different  classes  of  foods. 


NUTRITION.     ANIMAL   AND   VEGETABLE  FOODS   COMPARED. 


23 


Among  the  lower  animals  the  effect  upon  the  whole  system  of 
modifications  in  nutrition  produced  by  special  methods  of  feeding 
are  much  more  striking  than  in  man,  as,  for  example,  the  feeding  of 
the  queen  bee,  and  of  draught  horses  as  compared  with  racers. 

Animal  food  is  believed  by  many  to  make  the  blood  rich  in  fibrin 
and  corpuscles,  and  to  increase  the  mineral  salts,  especially  the  phos- 
phates; it  both  repairs  the  old  and  forms  new  tissue;  it  improves  the 
condition  of  the  muscles,  which  are  made  firmer  than  they  are  upon 
a  vegetable  diet,  and  it  favours  the  reduction  of  stored-up  or  surplus 
fat.  Under  some  conditions  it  may  produce  a  part  of  the  body  fat, 
although  most  of  it  is  derived  from  other  sources  (see  Obesity).  It 
also  increases  the  quantity  of  urates,  phosphates,  sulphates,  and  urea 
normally  present  in  the  urine,  and  tends  to  make  the  fluids  of  the 
body  somewhat  more  acid  or  less  alkaline. 

Bauer  (Dietary  of  the  Sick)  says:  "The  functional  activity  and 
resisting  power  of  the  organism  seem  to  be  essentially  connected 
with  the  presence  of  an  ample  supply  of  albumin." 

Animal  food  requires  a  considerable  quantity  of  oxygen  for  its 
complete  combustion,  and  a  diet  of  this  nature  increases  the  demand 
for  oxygen  and  favours  its  consumption.  Meat  in  general  has  a  more 
stimulating  effect  upon  the  system  and  is  more  "strengthening" 
than  vegetable  food,  and  it  gives  rise  to  sensations  of  energy  and 
activity.  A  meal  consisting  of  meat  remains  an  hour  or  two  longer 
in  the  stomach  than  a  purely  vegetable  meal.  It  seems  to  satisfy  the 
cravings  of  hunger,  bulk  for  bulk,  to  a  greater  extent  and  for  a 
longer  time  than  vegetable  food,  and  a  man  can  live  longer  upon  ex- 
clusive nitrogenous  food  than  upon  exclusive  carbonaceous  food. 
Animal  food  occupies  less  space  in  the  stomach,  and  is  more  portable 
than  vegetable  food.  Moreover,  albuminous  foods  can  be  eaten  longer 
alone  without  exciting  loathing,  as  a  rule,  than  can  fats,  sugars,  or 
even  some  pure  starches.  In  fact,  there  is  a  constant  tendency  to  eat 
too  much  meat,  and  when  its  effects  are  not  counterbalanced  by  free 
outdoor  exercise,  it  produces  an  excess  of  waste  matter  which  accu- 
mulates and  causes  biliousness,  and  sometimes  lithiasis,  gout,  etc. 
Fothergill  wrote  :  "  In  an  excess  of  nitrogenised  food  we  find  the 
cause  of  much  of  the  lithiasis,  or  gout,  whether  regular,  irregular,  or 
suppressed,  with  which  we  are  brought  into  contact."  A  carbona- 
ceous diet  taxes  the  excretory  organs  to  a  lesser  degree  than  animal 
food. 

Sir  H.  Thompson  says:  "  It  is  a  vulgar  error  to  regard  meat 
in  any  form  as  necessary  to  life."  Nitrogenous  food  man  must 
have,  but  it  need  not  necessarily  be  in  the  form  of  meat,  which  "to 
many  has  become  partially  desirable  only  by  the  force  of  habit,  and 
because  their  digestive  organs  have  thus  been  trained  to  deal 
with  it." 


24 


FOODS  AND  FOOD  PREPARATIONS. 


This  is  no  doubt  true,  but  the  training  has  become  so  strongly  a 
matter  of  heredity  through  many  centuries  that  those  who  possess 
it  are  certainly  in  better  health  for  a  reasonable  allowance  of  meat  in 
their  dietary.  Errors  in  diet  are  far  more  common  on  the  side  of 
excessive  meat  eating  than  the  eating  of  too  much  vegetable  food, 
especially  among  civilised  communities.  In  the  temperate  zones  an 
increase  in  prosperity,  together  with  the  improvements  made  in  the 
methods  of  preparing  and  preserving  meat  as  well  as  those  in  breed- 
ing cattle  for  market  purposes,  tend  to  increase  the  habit  of  meat 
eating.  The  estimate  commonly  given,  in  which  meat  should  occupy 
one  fourth  and  vegetable  food  three  fourths  of  a  mixed  diet,  is  over- 
stepped by  many  persons  with  whom  the  proportion  may  be  two  to 
four.  There  is  often  too  much  eating  of  cold  meats  at  luncheon  for 
the  interests  of  health. 

The  proper  association  of  different  foods  always  keeps  healthy 
men  in  better  condition  than  too  long  continuance  of  any  selected 
diet  system. 

Sir  H.  Thompson,  in  speaking  of  the  advantages  of  a  well-pro- 
portioned diet,  says :  "  A  preference  for  the  high  flavours  and  stimu- 
lating scents  peculiar  to  the  flesh  of  vertebrate  animals  mostly 
subsides  after  a  fair  trial  of  milder  foods  when  supplied  in  variety. 
.  .  .  The  desire  for  food  is  keener,  the  satisfaction  in  gratifying  ap- 
petite is  greater  and  more  enjoyable  on  the  part  of  the  general  light 
feeder,  than  with  the  almost  exclusively  flesh  feeder.  .  .  .  Three 
fourths  at  least  of  the  nutrient  matters  consumed  are  from  the  ani- 
mal kingdom.  A  reversal  of  the  proportions  indicated — that  is,  a 
fourth  only  from  the  latter  source,  with  three  fourths  of  vegetable 
produce — would  furnish  greater  variety  for  the  table,  tend  to  main- 
tain a  cleaner  palate,  increased  zest  for  food,  a  lighter  and  more 
active  brain,  and  a  better  state  of  health  for  most  people  not  en- 
gaged in  the  most  laborious  employments  of  active  life." 

This  comment  is  more  applicable  to  the  upper  classes  in  England 
than  in  this  country,  where  more  attention  is  given  to  the  cultivation 
and  cooking  of  fresh  vegetables  and  the  preparation  of  vegetable 
products. 

Letheby  wrote  :  "  The  best  proportions  for  the  common  wants  of 
the  animal  system  are  about  nine  of  fat,  twenty-two  of  flesh-forming 
substances,  and  sixty-nine  of  starch  and  sugar." 

Meats  which  are  deficient  in  fat  are  usually  eaten  with  added  fat. 
Thus  bacon  is  eaten  with  veal,  liver,  and  chicken,  and  most  fish  are 
cooked  with  butter  or  oil.  Similarly,  butter,  eggs,  or  cream  are 
mixed  with  amylaceous  foods,  such  as  rice,  sago,  potatoes,  etc.,  which 
are  lacking  in  fat,  and  fat  containing  cheese  is  added  to  macaroni. 
Bacon  is  added  to  beans,  and  pork  to  greens. 

"Whenever  one  kind  of  food  is  wanting  in  any  particular  constitu- 


NUTRITION.     ANIMAL   AND   VEGETABLE   FOODS   COMPARED. 


25 


ent,  we  invariably  associate  it  with  another  that  contains  an  excess  of 
it  "  (Letheby). 

If  a  labouring  man  is  allowed  an  ordinary  meat  ration  he  requires 
in  addition,  to  obtain  his  requisite  carbon  of  fat,  346  grammes,  and 
of  starch  596  grammes  (Voit).  But  he  would  soon  tire  of  such  a  quan- 
tity of  either  of  these  two  food  classes  alone,  and  he  does  better 
to  eat  some  of  each. 

The  carnivorous  animal  fed  upon  lean  meat  alone  requires  a  daily 
supply  equal  to  one  twentieth  of  his  body  weight,  but  if  a  little  fat 
be  added  he  needs  much  less. 

Animal  food  is  often  said  to  be  more  stimulating  to  the  passions 
than  vegetable  food,  and  the  general  character  of  carnivorous  ani- 
mals is  more  savage  than  that  of  herbivorous,  although  the  angered 
bull  is  as  fierce  as  any  carnivore.  It  is  doubtful,  however,  whether 
this  is  attributable  so  much  to  their  different  diet  as  to  many  other 
conditions  which  have  contributed  through  the  survival  of  the  fittest 
to  their  differentiation.  Carnivorous  animals  are  obliged  to  work 
and  fight  for  their  food ;  they  obtain  it  at  uncertain  and  infrequent 
intervals,  often  when  made  ravenous  by  long  periods  of  fasting. 
Herbivorous  animals,  on  the  contrary,  always  have  their  food  at 
hand,  obtainable  with  no  labour  other  than  that  of  eating.  The 
Polynesian  warrior  is  more  ferocious  at  times  on  a  diet  of  plantains 
than  the  Eskimo,  who  eats  nothing  but  meat  and  fats. 

Formerly  nitrogenous  foods  were  believed  to  furnish  the  chief 
supply  of  energy  for  the  body,  especially  in  the  production  of  mus- 
cular force;  but  the  experiments  of  Parkes  and  others  made  some 
twenty-five  years  ago  did  much  to  modify  this  theory,  and  it  is  now 
believed  that  the  chief  value  of  nitrogenous  foodstuffs  lies  in  tissue 
formation  in  distinction  from  force  production,  which  is  maintained  by 
the  hydrocarbons.  Some  energy  is  undoubtedly  derived  from  nitro- 
genous material,  for  no  molecular  rearrangement  or  chemical  reac- 
tion can  take  place  without  altering  the  balance  of  energy,  but  the 
force  produced  by  combustion  of  proteids  is  insignificant  in  compari- 
son with  their  other  uses.  In  support  of  this  statement,  the  follow- 
ing facts  may  be  cited  as  abundantly  proved  :  i.  Severe  and  long-con- 
tinued muscular  exercise  does  not  cause  the  quantity  of  urea  in  the 
urine  to  be  materially  increased.  Urea  represents  the  ashes  of  pro- 
teid  material  and  increase  in  its  quantity  is  due  to  a  more  active  oxi- 
dation of  animal  food,  not  necessarily  to  tissue  waste.  2.  Muscular 
exercise,  on  the  contrary,  does  result  in  a  great  increase  in  the 
amount  of  CO,  eliminated  from  the  lungs,  which  is  primarily  derived 
from  the  combustion  of  hydrocarbons.  3.  Isolated  muscles  made  to 
contract  by  artificial  stimulation  when  contained  in  vacuo  under  a 
bell  glass  have  been  shown  to  produce  by  their  activity  large  quanti- 
ties of  COj,  but  no  urea.     4.  Prolonged  muscular  exercise  or  extraor- 


26  FOODS  AND  FOOD  PREPARATIONS. 

dinary  exertion  can  be  maintained  upon  a  diet  of  starchy  foods 
and  fat  without  meat;  and  during  the  period  following  the  exertion 
the  urea  is  not  increased  beyond  a  degree  which  is  readily  accounted 
for  by  a  slight  wasting  of  the  nitrogenous  tissues  of  the  body. 

A  man  cannot  perform  more  actual  muscular  labour  upon  an  ex- 
clusive diet  of  animal  food  than  of  starchy  food.  He  requires  abun- 
dant animal  food  to  replace  the  general  wear  and  tear  of  muscular 
tissue,  but  the  energy  for  muscular  contraction  is  not  derived  from 
nitrogenous  food,  but  from  carbohydrates,  the  former  being  used 
merely  to  keep  the  muscles  in  a  state  of  healthful  equilibrium. 
He  who  is  physically  feeble  and  who  lacks  muscular  power  cannot 
restore  that  power  by  an  exclusive  nitrogenous  diet.  A  man  fed 
upon  nitrogenous  diet  without  vegetable  food  may  not  work  as  well 
in  daily  labour  as  when  given  a  fair  proportion  of  the  latter;  but,  on 
the  other  hand,  he  is  better  fitted  for  sudden  arduous  exertion  than 
are  exclusive  vegetable  feeders, 

A  mixed  diet  is  therefore  the  only  rational  one  for  man,  and  it  is 
useless  to  reason  otherwise  from  analogy  with  the  lower  animals. 
The  ox  is  strong  and  performs  daily  labour  upon  a  grass  diet,  but  he 
extracts  a  larger  proportion  of  nitrogen  from  such  food  than  a  man's 
feebler  digestive  organs  could  enable  him  to  do.  The  proportion  of 
proteid  to  carbohydrate  is  i  to  4.7  in  such  food.  The  horse  is  fed 
upon  oats  when  it  is  desired  to  increase  his  spirit  and  activity,  and 
he  derives  more  nitrogen  from  them  than  does  man  from  his  oatmeal. 
The  lion  derives  great  strength  from  purely  nitrogenous  food,  but 
even  when  trained  he  is  wholly  unfit  for  the  continuous  exertion  that 
herbivores  can  endure. 

The  northern  Eskimo,  who  has  absolutely  no  starchy  or  saccha- 
rine food,  eats  fat  with  his  proteid  diet,  and  is  therefore  enabled  to 
acquire  energy  to  resist  extreme  cold  and  to  take  very  long  and 
fatiguing  sledge  journeys;  yet  he  is  no  stronger,  nor  as  strong,  as 
the  Central  African  negro,  who  lives  upon  a  diet  of  manioc  and  plan- 
tains, without  meat. 

Man  is  an  animal  of  extraordinary  adaptability  to  his  environ- 
ment, and  one  must  be  consequently  guarded  in  making  dogmatic 
statements  in  regard  to  his  diet,  and  such  observations  as  the  above 
must  be  taken  as  applying  only  generally,  for  it  seems  possible  for 
either  class  of  foods  to  supplement  to  some  extent  the  functions  of 
the  other.  This  fact  is  illustrated  in  disease  as  well  as  in  health. 
For  example,  in  the  earlier  stages  of  diabetes  sugar  is  formed  from 
farinaceous  and  saccharine  food  almost  exclusively,  but  in  the  ad- 
vanced stages,  when  these  substances  are  withheld,  it  can  undoubtedly 
be  made  from  proteid  material. 

The  combinations  of  foods  which  are  by  analysis  shown  to  con- 
tain quantities  of  proteids,  starch,  and  fat,  have  a  very  different  effect 


NUTRITION.    ANIMAL   AND  VEGETABLE  FOODS  COMPARED. 


27 


in  overtaxing  the  digestive  organs  according  to  the  particular  form 
in  which  their  ingredients  exist. 

It  is  a  popular  belief  that  meat  requires  more  energy  for  digestion 
than  starchy  food,  but  in  health  this  is  probably  not  true,  provided 
both  varieties  of  food  are  taken  in  correct  proportion,  for  it  certainly 
would  be  a  strain  upon  the  digestive  system  to  be  obliged  to  derive 
all  the  carbon  needed  from  an  exclusive  meat  diet,  just  as  it  over- 
taxes the  alimentary  canal  to  obtain  sufficient  nitrogenous  material 
from  an  exclusive  vegetable  diet.  It  cannot  be  said  didactically  that 
a  piece  of  beef  is  more  or  less  digestible  than  a  potato,  and  that  it 
taxes  the  energies  of  the  digestive  organs  to  a  greater  extent, 
although  it  is  more  completely  assimilated  and  leaves  less  waste  in 
the  intestme.  The  whole  question  devolves  upon  a  true  balance  of 
the  ingredients  of  a  mixed  diet.  As  regards  the  actual  complexity 
of  the  digestive  processes  of  the  several  classes  of  food,  there  is  but 
little  difference :  both  starches  and  proteids  pass  through  interme- 
diate stages  on  the  way  to  the  formation  of  their  completed  products, 
and  fermentation  cannot  be  said  to  present  greater  difficulty  in  the 
one  case  than  in  the  other.  For  man,  certainly,  Nature  never  in- 
tended that  all  the  nutrition  of  the  body  should  be  derived  from  any 
one  class  of  food  stuff  which  would  require  the  use  of  certain  di- 
gestive juices,  and  imply  the  disuse  of  others  which  are  normally 
present. 

A  diet  of  animal  food  is  much  less  fattening  than  a  vegetable 
regimen  or  than  carbohydrates  with  a  fair  proportion  of  fats,  but  a 
stout  man  will  not  necessarily  endure  fatigue,  or  even  starvation, 
any  better.  On  the  other  hand,  to  increase  the  proteid  substances 
of  the  body  an  albuminous  diet  with  but  little  carbohydrate  is  neces- 
sary. Men,  unless  greatly  emaciated,  have  a  reserve  store  of  energy 
in  their  bodies  sufficient  to  maintain  their  animal  heat  and  keep  them 
alive  for  from  seven  to  nine  days,  and  this  is  true  whether  they  have 
been  meat  eaters  or  vegetarians.  Storage  of  fat  will  help  them  out  in 
emergencies,  but  if  it  has  been  overdone — i.  e.,  if  there  is  too  much 
fat  in  the  tissues — they  may  be  weakened  by  it  and,  although  they 
have  the  material  for  force  production  on  hand,  they  are  unable  to 
utilise  it,  and  are  worse  off  than  if  they  were  spare.  (See  Obesity 
and  Leanness,  pages  599  and  615). 

Bauer  says:  "The  material  effects  of  albumin  and  of  fat  in  the 
system  are  in  a  certain  sense  opposed,  for  the  former  increases  the 
tissue  waste  and  secondarily  the  oxidation,  while  fat  induces  the  op- 
posite effects." 

Animal  food  is  easily  cooked,  and  in  the  process  develops  more 
flavour  than  does  vegetable  food. 


28  FOODS  AND   FOOD  PREPARATIONS. 

VEGETARIANISM. 

In  regard  to  an  exclusive  or  almost  exclusive  vegetable  diet  for 
man,  the  universal  experience  has  been  that  while  it  may  keep 
him  in  apparent  health  for  some  time,  it  eventually  results  in  a 
loss  of  strength  and  general  resisting  power  against  disease,  which 
becomes  evident  after  some  months,  if  not  before. 

Of  vegetarianism  Bauer  says:  "The  beneficial  effects  of  vege- 
tarianism certainly  do  not  depend  on  the  fact  that  its  followers 
take  no  meat,  and  still  more  no  animal  food,  but  on  their  giving  up 
their  former  bad  habits." 

No  doubt  much  of  the  alleged  benefit  of  vegetarianism  is  due 
to  the  greater  freedom  of  action  of  the  bowels,  induced  by  the  use 
of  bran  bread  and  other  coarse  articles  of  food. 

It  is  impossible  to  subsist  for  any  length  of  time  on  a  diet  which 
does  not  contain  a  considerable  quantity  of  nitrogen,  which  con- 
stitutes so  important  an  element  in  the  composition  of  the  great 
majority  of  structures  of  the  body,  and,  in  fact,  of  protoplasm  itself. 

Attempts  have  from  time  to  time  been  made,  for  economic  rea- 
sons, to  furnish  large  bodies  of  labouring  men,  employed  by  con- 
tract or  otherwise,  with  a  purely  vegetable  diet ;  but  this  diet  is 
found  to  defeat  its  own  ends,  in  that  the  maximum  of  labour  can- 
not be  maintained  by  men  who  are  fed  exclusively  on  vegetable 
food,  although  some  carbohydrates  are  essential.  It  gradually 
induces  a  condition  of  muscular  weakness  and  languor  with  dis- 
inclination for  either  physical  or  mental  work. 

In  referring  to  graminivorous  people,  like  the  Bengalese,  Cham- 
bers wrote :  **  If  required  to  exert  themselves  in  any  unusual  way 
when  food  is  deficient,  they  simply  die.  The  reason  is  evident — 
they  have  been  living  on  their  own  tissues,  and  the  small  quantity 
of  albuminous  matter  in  grain  is  a  long  time  in  building  them  up 
again,  so  that  for  weeks,  or  even  months,  their  muscles  are  in  a  state 
of  atrophy."  It  is  found,  too,  that  their  food  must  be  very  gradu- 
ally altered  if  they  are  to  change  to  a  mixed  diet. 

Animal  food  in  some  form  must  be  regarded  as  absolutely  essen- 
tial for  all  races  of  man.  When  the  diet  of  enthusiastic  "  vege- 
tarians "  is  carefully  analysed  it  is  found  that  the  strictly  hydro- 
carbonaceous  food  is  supplemented  by  such  articles  as  milk,  eggs, 
etc.,  which  are  used  in  cooking  or  in  other  ways,  although  the  con- 
sumption of  nitrogenous  food  may  appear  very  much  restricted. 

It  is  believed,  by  Giibler  and  others  that  an  exclusive  vegetable 
diet  eventually  develops  an  atheromatous  condition  of  the  arteries, 
on  account  of  the  large  proportion  of  mineral  salts  which  thus  enter 
the  blood,  but  the  evidence  of  this  is  not  convincing.  It  is  also 
claimed  that  a  vegetable  diet  favours  the  deposition  of  mineral  salts 


VEGETARIANISM. 


29 


in  different  parts  of  the  body,  as  phosphatic  stone,  gravel,  and 
the  tartar  on  the  teeth,  and  that  living  upon  coarse  cereals  alone 
makes  the  skin  rough,  and  the  individual  dull,  heavy,  and  ill-tem- 
pered. 

While  it  is  quite  true  that  some  kinds  of  vegetables  contain  a  large 
proportion  of  nitrogenous  substance,  it  exists  in  a  form  in  which 
it  is  less  easily  assimilated  than  animal  proteid.  In  vegetable  foods 
nitrogenous  materials  are  more  or  less  closely  mingled  with  starch. 
Cellulose  itself  is  often  very  tough  and  insoluble  in  the  digestive 
fluids,  so  that  as  large  a  proportion  of  albuminous  matters  as  17  per 
cent  may  be  wasted,  while  not  over  3  per  cent  of  the  proteid  mat- 
ter of  animal  food  remains  undigested  (Yeo).  This  is  an  im- 
portant illustration  of  the  fact  that  one  must  not  be  guided  by 
chemical  composition  alone  in  selecting  the  proper  dietary  for  man, 
but  the  question  should  rather  depend  upon  the  actual  nutrient 
value  of  the  food  when  absorbed.  A  food  in  its  ultimate  analysis 
may  yield  the  necessary  chemical  ingredients  for  a  nutritious  diet, 
and  yet  from  imperfect  digestibility  it  may  prove  of  little  service  for 
actual  nutriment. 

There  are  many  facts  in  Nature  in  addition  to  those  already 
discussed  which  indicate  without  doubt  that  man  from  his  earliest 
prehistoric  days  has  been  omnivorous,  adapting  himself  to  his 
surroundings  and  eating,  in  his  primitive  condition,  whatever  his 
environment  afforded,  with  least  expenditure  of  labour  to  obtain  it, 
now  vegetable,  now  animal  food.  This  is  shown  in  the  structure  of 
the  teeth  in  prehistoric  skulls,  and  in  the  length  of  the  alimentary 
canal  and  character  of  the  digestive  organs  and  secretions  as  at 
present  existing. 

The  ancient  Britons  are  known  to  have  subsisted  chiefly  upon 
acorns,  berries,  roots,  leaves,  etc.,  but  other  primitive  tribes  ate  fish, 
shellfish,  and,  when  they  could  kill  it,  game. 

A  brief  glance  at  the  dietetic  habits  of  the  more  primitive  tribes 
of  mankind  at  present  living  shows  that  no  arguments  can  be 
drawn  from  them  as  to  the  advantages  of  any  particular  class  of 
foods. 

Many  savage  tribes  to-day  live  very  largely  upon  vegetable  food, 
although  an  exclusive  vegetable  diet  is  almost  unknown  among 
them,  and  most  of  them  eat  meat  whenever  they  can  obtain  it,  or 
they  supplement  their  food  by  nitrogenous  articles,  such  as  milk, 
eggs,  fish,  and  insects  of  various  kinds.  Even  the  Chinese  and 
Japanese,  who  subsist  principally  upon  simple  farinaceous  food,  such 
as  rice,  eat  also  eggs,  fish,  pork,  and  chicken.  On  the  other  hand, 
there  are  tribes  of  men  inhabiting  very  hot  countries  who  eat  con- 
siderable quantities  of  meat,  as,  for  example,  the  Nubian  Arabs 
and  Abyssinians.     Some  natives  along  the  Congo  subsist  solely  upon 


20  FOODS  AND  FOOD  PREPARATIONS. 

fruits  and  insects.  The  Mongolian  lives  by  his  herds — upon  milk 
products  and  meat — bread  being  scarcely  known  to  him.  The  Aus- 
tralian savage  is  omnivorous,  and,  having  no  cereals,  he  subsists 
upon  berries,  beans,  pith,  nuts,  honey,  larvae,  ants,  etc.  The  Papuan 
Islanders  live  chiefly  upon  sago,  fish,  and  fruits.  The  New  Cale- 
donians were  formerly  cannibals,  but  are  now  vegetarians  by  prefer- 
ence, and  prefer  to  trade  their  pigs  and  goats  with  passing  ships 
rather  than  to  eat  them. 

Vegetarianism  in  former  times  has  had  many  famous  advocates. 
Shelley  was  a  vegetarian,  and  Goldsmith  also  at  one  time.  There 
is  a  vegetarian  society  in  England  which  has  established  restaurants 
in  London,  Manchester,  and  several  other  localities.  There  is  a  sim- 
ilar organisation  in  this  country.  The  recent  epidemic  of  esoteric 
Buddhism  has  induced  some  persons  to  adopt  vegetarian  habits,  but 
few  of  them  adhere  to  them  strictly  or  for  long. 


THE  CLASSES  OF   FOODS. 

L  WATER. 

It  is  estimated  that  water  composes  about  70  per  cent  of  the 
entire  body  weight,  and  it  is  an  almost  universal  solvent.  Its  im- 
portance to  the  system,  therefore,  cannot  be  overrated.  The  elastic- 
ity or  pliability  of  muscles,  cartilages,  and  tendons,  and  even  of 
bones,  is  in  great  part  due  to  the  water  which  these  tissues  contain. 
As  Solis-Cohen  says,  "  the  cells  of  the  body  are  aquatic  in  their 
habits."  The  amount  of  water  required  by  a  healthy  man  in  twenty- 
four  hours  is,  on  the  average,  between  50  and  60  ounces,  besides 
about  25  ounces  taken  in  as  an  ingredient  of  solid  food,  thus  making 
a  total  of  75  to  85  ounces.  The  elimination  of  this  water  is  divided 
as  follows :  28  per  cent  through  the  skin,  20  per  cent  through  the 
lungs,  50  per  cent  through  the  urine,  2  per  cent  through  other  secre- 
tions and  the  faeces.  This  is,  of  course,  a  very  general  computation, 
for  there  is  constant  variation  in  the  activity  of  different  organs. 

A  large  proportion  of  the  water  is  taken  in  the  form  of  beverages 
composed  chiefly  of  it,  and  by  many  persons  they  are  substituted  for 
plain  water  altogether.  In  many  countries  light  wines,  beer,  and 
other  fermented  drinks  wholly  replace  drinking  water.  This  may  be 
due  to  habit  and  custom,  or  to  necessity  from  lack  of  pure  natural 
water,  but  in  all  cases  the  quantity  of  water  required  to  maintain  the 
functions  of  the  body  in  healthful  activity  remains  the  same,  whether 
it  be  drunk  pure  or  in  beverages,  or  taken  with  succulent  fruits  and 
vegetables,  or  in  milk,  koumiss,  etc. 

One  of  the  most  universal  dietetic  failings  is  neglect  to  take 
enough  water  into  the  system. 


WATER.  21 

Uses  of  Water  in  the  Body. — The  uses  of  water  in  the  body 
may  be  summarised  as  follows  : 

1.  It  enters  into  the  chemical  composition  of  the  tissues. 

2.  It  forms  the  chief  ingredient  of  all  the  fluids  of  the  body  and 
maintains  their  proper  degree  of  dilution. 

3.  By  moistening  various  surfaces  of  the  body,  such  as  the  mu- 
cous and  serous  membranes,  it  prevents  friction  and  the  uncomforta- 
ble symptoms  which  might  result  from  their  drying. 

4.  It  furnishes  in  the  blood  and  lymph  a  fluid  medium  by  which 
food  may  be  taken  to  remote  parts  of  the  body  and  the  waste  mat- 
ter removed,  thus  promoting  rapid  tissue  changes. 

5.  It  serves  as  a  distributer  of  body  heat. 

6.  It  regulates  the  body  temperature  by  the  physical  processes  of 
absorption  and  evaporation. 

All  protoplasmic  activity  in  cells  ceases  at  once  if  they  become 
dry.  Elementary  cells,  such  as  the  amoeba,  cease  to  move,  to  digest, 
or  to  show  any  form  of  irritability  or  functional  activity  when  dry, 
but  if  water  be  added  to  them  their  functions  will  be  resumed,  show- 
ing that  they  have  been  suspended  and  not  necessarily  destroyed. 

The  taking  of  much  water  into  the  stomach  by  its  mechanical 
pressure  excites  peristalsis.  One  or  two  tumblerfuls  of  cold  water 
taken  into  an  empty  stomach  in  the  morning  on  rising  favour  evacua- 
tion of  the  bowels  in  this  way.  The  water,  moreover,  is  quickly  ab- 
sorbed and  temporarily  increases  the  fulness  of  the  blood  vessels. 
This  promotes  intestinal  secretion  and  peristalsis.  The  increased 
activity  of  the  lower  bowel  is  explained  in  this  way  rather  than  by 
the  idea  that  the  water  itself  reaches  the  colon  and  washes  out  its 
contents. 

Lukewarm  water  acts  as  an  emetic  if  drunk  in  large  quantity. 
This  action  fails  above  95°  F.  and  below  60°  F.,  and  is  most  efficient 
at  about  90°  F. 

Purity  of  Water. — Of  recent  years  the  importance  of  insuring 
the  purity  of  drinking  water  has  become  more  and  more  appreciated, 
and  an  intelligent  public  is  now  aroused  to  the  absolute  necessity  of 
protecting  their  supplies  of  drinking  water  from  contamination  with 
sewage,  decomposing  animal  matter,  etc.  So  general  has  the  interest 
in  this  subject  become  in  this  country  that  many  new  laws  have  been 
passed  within  the  last  three  or  four  years  to  protect  the  water  supply 
of  large  cities  and  towns.  The  subject  is  not  confined  to  water  alone, 
but  includes  ice  as  well,  for  many  of  the  germs  and  organic  impuri- 
ties of  water  are  not  destroyed  by  freezing,  and  impure  ice  added 
to  pure  water  contaminates  it.  It  has  been  very  clearly  proved  that 
many  infections  may  be  conveyed  through  the  agency  of  water ; 
among  the  most  important  of  these  are  the  germs  of  typhoid  fever, 
dysentery,  and  cholera.     Very  possibly,  also,  the  malarial  plasmodium 


52 


FOODS  AND  FOOD  PREPARATIONS. 


can  be  thus  conveyed,  and  the  germs  of  other  diseases,  such  as  tuber- 
culosis and  diphtheria,  when  they  obtain  access  to  drinking  water. 
Water  may  be  further  rendered  unwholesome  by  moulds,  ferments, 
and  excess  of  decaying  vegetable  matter.  (For  water  contaminated 
with  lead,  see  Lead  Poisoning).  Water  from  shallow  wells  and  wells 
near  drains,  barnyards,  cesspools,  or  privies  is  wholly  unfit  for 
drinking. 

Varieties  of  Drinking  Water. — Water  containing  a  moderate 
quantity  of  mineral  salts,  4  or  5  grains  to  the  gallon,  is  not  to  be 
regarded  as  impure,  but  the  composition  as  well  as  the  quantity  of 
these  salts  affect  its  power  as  a  solvent  in  the  tissues,  and  may  exert 
a  very  decided  influence  upon  the  digestive  system  when  present  in 
the  proportion  of  60  or  70  grains  to  the  gallon.  The  mineral  waters 
may  contain  much  more. 

Water  is  usually  unwholesome  for  drinking  in  volcanic  and  ba- 
saltic mountain  regions,  and  because  of  organic  impurities  it  is  bad 
in  marshy  regions. 

Hard  and  Soft  Water. — An  excess  of  lime  salts  and  of  other  min- 
eral matters  in  water  produces  constipation,  flatulence,  indigestion, 
and  favours  the  formation  of  calcareous  deposits  in  various  parts  of 
the  body.  "  Hard  water  "  unites  with  soap  and  makes  it  less  soluble, 
so  that  it  is  difficult  to  cleanse  the  hands  with  it.  It  also  roughens 
the  skin  and  dries  the  mucous  membranes.  By  boiling,  the  hardness 
of  water,  which  is  due  to  the  presence  of  earthy  carbonates,  is  dimin- 
ished, for  the  carbonic  acid,  which  aids  in  holding  them  in  suspen- 
sion, is  driven  off.  Water  is  also  improved  for  drinking  by  filtering 
through  a  filter  paper,  or  clean  absorbent  cotton  on  a  funnel.  Boil- 
ing the  water  does  not  precipitate  neutral  and  alkaline  salts,  and  a 
purgative  action  may  still  remain  if  they  are  present. 

Hard  water  is  made  more  digestible  by  converting  it  into  barley 
or  oatmeal  water.  Water  which  contains  sulphate  of  lime  causes 
gastric  distress  and  dyspepsia,  and  it  may  form  calculi.  "  Soft  water  " 
is  simply  water  which  is  free  from  objectionable  salts.  It  is  more 
wholesome  than  hard  water.  Hard  and  soft  water  have  well-known 
characteristics  in  regard  to  their  effect  upon  the  cooking  of  food. 

Rain  Water. — Next  to  clear  mountain-spring  water  which  has  run 
through  gravel  and  been  well  aerated,  rain  water  at  the  close  of  a 
shower  is  the  purest  form  of  natural  water,  excepting  where  it  has 
fallen  through  a  very  dusty  or  smoky  atmosphere  or  has  run  over  a 
dirty  roof.  The  first  drops  of  a  shower  carry  down  with  them  the 
impurities  of  the  air,  including  traces  of  ammonia  and  nitric  acid. 
No  natural  water  possesses  absolute  chemical  purity,  but  water  col- 
lected at  the  end  of  a  hard  or  long  shower  is  very  pure,  Jiaving  been 
distilled  by  previous  evaporatioa  It  may  also  be  purified  by  per- 
colation through  surface  soil. 


WATER. 


33 


River  water  which  has  run  over  a  rock  or  gravel  bed,  and  has 
been  well  aerated,  is  quite  pure  and  assimilable  if  properly  protected 
from  sources  of  pollution.  Free  oxidation  makes  much  organic 
matter  harmless.  Flowing  water  by  oxidation  and  dilution  becomes 
purified  to  a  great  extent  of  injurious  organic  matter,  but  is  not 
necessarily  deprived  of  living  germs  of  contagion,  such  as  those  of 
typhoid  fever  or  cholera,  and  the  question  whether  their  number  and 
virulence  is  at  a41  diminished  in  such  water  is  still  a  matter  of  con- 
troversy. 

It  is  now  so  well  recognised  that  the  impurities  of  water  which 
are  chiefly  dangerous  to  man  are  of  organic  germ  origin  that  in 
examining  water  which  is  suspected  of  being  the  cause  of  a  typhoid- 
fever  epidemic  a  chemical  analysis  of  the  nitrates  present,  unaccom- 
panied by  a  proper  bacteriological  examination,  is  entirely  useless. 

Distilled  Water. — Distilled  water  is  absolutely  pure,  but  it  has  a 
flat  or  metallic  taste  from  absence  of  air  and  salts.  It  is  now  fur- 
nished for  drinking  at  many  hotels,  and  is  largely  in  use  on  vessels 
at  sea.  Our  modern  naval  vessels  carry  apparatus  for  its  manu- 
facture. Distilled  water  has  been  recommended  as  a  solvent  for 
calculi,  but  it  is  of  doubtful  efificacy.  It  erodes  lead  pipes  and 
cisterns. 

Filtered  Water. — Filtration  as  employed  to  render  drinking  water 
more  pure  is  a  very  delusive  process.  A  great  variety  of  patent 
filters  have  been  devised,  and  they  have  the  power  of  making  water 
appear  pure  by  decolourising  it  and  removing  the  larger  organic 
particles  and  grosser  impurities  which  it  may  contain,  but  it  has 
been  conclusively  shown  that  the  bed  of  a  filter  which  has  been  in 
use  for  a  short  time  furnishes  a  favourable  soil  or  culture  medium 
for  the  development  of  germs,  which  increase  very  rapidly  until  they 
reach  such  numbers  that  they  are  washed  out  with  the  filtered  water, 
rendering  it  much  more  injurious,  in  some  instances,  than  it  was  be- 
fore. Many  of  these  germs  are  doubtless  harmless,  but  if  the  mi- 
crobes of  infectious  diseases  once  gain  access  to  such  a  soil  they 
multiply  and  become  highly  dangerous. 

Boiled  Water. — Boiled  water  is  antifermentative,  antiseptic,  and 
cleansing. 

The  object  of  boiling  the  water  which  is  to  be  used  for  drinking 
purposes,  or  in  the  preparation  of  food,  is  to  free  it  from  all  organic 
impurities,  and  in  some  cases  to  precipitate  salts  of  lime.  There  are 
no  forms  of  germs,  and  there  are  no  ferments,  either  organised  or 
unorganised,  which  are  not  killed  by  a  longer  or  shorter  exposure  to 
the  temperature  of  boiling  water.  The  process  consists  in  the  appli- 
cation of  heat  to  water  in  sufficient  degree  to  expand  the  air  which  it 
naturally  absorbs  and  cause  it  to  rise  to  the  surface  in  bubbles  of 
various  sizes.     If  the  water  contains  gases  of  decomposition  they  are 


y 


34 


FOODS   AND   FOOD   PREPARATIONS. 


expelled,  and  the  odour  is  most  foul  just  before  the  boiling  point  is 
reached;  later  it  passes  off,  showing  that  the  water  is  fit  to  drink-. 
When  the  water  is  cooled  and  drunk  it  is  found  to  taste  "flat"  or 
insipid,  but  it  may  be  freshened  by  pouring  it  through  the  air  from 
one  vessel  to  another  or  by  shaking  it  with  air  in  a  carafe.  Water 
should  always  be  boiled  before  being  drunk  if  there  is  the  slightest 
suspicion  as  to  its  purity.  The  population  of  the  larger  Chinese 
cities  is  exceedingly  dense,  and  the  drinking  water  used  by  the  in- 
habitants is  impregnated  with  all  manner  of  filth,  but  it  is  believed 
that  the  custom  of  the  natives  of  using  tea  infused  with  boiling 
water,  or  even  drinking  hot  water,  protects  them  to  a  great  extent 
from  the  ravages  of  certain  microbic  diseases. 

The  special  dietetic  uses  of  water  \^\\\  receive  attention  under  the 
appropriate  headings  of  different  diseases. 

Water  may  be  of  service  to  eliminate  waste  in  various  renal  dis- 
eases, gout,  lithiasis,  oxaluria,  renal  inadequacy,  fevers,  and  infectious 
diseases.  If  drunk  too  freely  with  meals  it  lessens  the  activity  of 
the  saliva.  Water  drunk  towards  the  conclusion  of  the  gastric  diges- 
tion of  a  meal  (i.  e.,  two  or  three  hours  after  taking  food)  serves  to 
dilute  the  contents  of  the  stomach  and  wash  it  more  readily  into  the 
intestine.  If  stomach  digestion  has  been  slow  and  feeble,  so  that 
the  whole  process  has  been  greatly  prolonged,  the  drinking  of  six  or 
eight  ounces  of  water,  either  hot  or  cold,  two  hours  or  more  after 
taking  food  will  facilitate  its  digestion.  Water  is  highly  useful  in 
constipation,  and  it  is  more  quickly  absorbed  from  the  stomach 
when  the  tension  in  the  gastric  vessels  is  low. 

It  is  imperatively  needed  after  severe  haemorrhage,  or  after  the 
sudden  loss  of  it  from  the  system  from  any  cause,  such  as  the  evacu- 
ations of  cholera  morbus,  Asiatic  cholera,  etc. 

It  is  to  be  restricted  in  dilatation  of  the  stomach,  the  secretion  of 
weak  gastric  juice,  and  sometimes,  but  not  always,  in  diabetes  insipi- 
dus, diabetes  mellitus,  ascites  and  other  dropsies,  anasarca,  and  in 
some  forms  of  heart  disease  and  obesity. 

The  daily  quantity  of  water  ordinarily  drunk  varies  between  two 
and  a  half  and  four  pints.  About  one  and  a  half  pint  more  is  taken 
in  the  food,  and  four  or  five  and  a  half  pints  are  therefore  lost 
through  the  emunctories. 

Foods  which  contain  most  water  are  milk  and  succulent  fruits, 
such  as  grapes,  oranges,  grape  fruit,  lemons,  watermelons,  etc.,  and 
vegetables  like  the  tomato,  squash,  and  many  others  of  tropical 
origin.  All  vegetables  contain  more  water  than  meats,  and  many, 
but  not  all,  ripe  fruits  contain  more  than  vegetables. 

Excess  of  Water. — There  is  a  remarkable  tendency  on  the 
part  of  the  blood  to  maintain  an  equilibrium  as  regards  its  own  com- 
position, volume,  and  density.     When  a  large  supply  of  water  is  re- 


WATER. 


35 


ceived  in  the  alimentary  canal  and  absorbed  by  the  blood  vessels, 
the  blood  is  momentarily  diluted  and  the  blood  pressure  slightly 
raised,  although  the  latter  effect  will  depend  upon  the  facility  with 
which  the  blood  vessels  are  dilated.  The  blood  immediately  dis- 
tributes the  water  thus  absorbed,  and  the  slightly  increased  pressure, 
as  well  as  the  diluted  character  of  the  blood,  hastens  the  elimination 
of  water  from  the  various  gland  surfaces.  The  kidneys  are  particu- 
larly sensitive  in  this  respect,  and  when  in  normal  condition  are  the 
great  regulators  of  the  composition  of  the  blood  and,  indirectly,  of 
blood  pressure  by  means  of  the  elimination  of  water.  Perspiration 
is  increased.  There  is  a  tendency  also  for  all  the  tissues  to  keep 
abundantly  supplied  with  water  ;  a  larger  amount  of  aqueous  va- 
pour is  exhaled  from  the  surface  of  the  lungs,  and  the  digestive 
secretions  are  increased  in  volume.  The  blood  may  subsequently 
become  more  dense  than  before,  owing  to  the  increased  functional 
activity  of  different  organs.  More  nutriment  is  absorbed  and  more 
carbonic  acid  is  exhaled,  and  urea  and  uric  acid  may  be  slightly  in- 
creased. 

If  very  large  quantities  of  water,  or  any  fluids  consisting  chiefly  of 
water,  are  imbibed  through  a  long  period,  they  tend  to  overwork 
the  kidneys  and  produce  various  alterations  in  the  tissues.  Practi- 
cally, however,  it  seldom  happens,  excepting  in  some  forms  of  gastric 
or  mtestinal  disorder,  and  other  instances  mentioned  above,  that  too 
much  water  is  taken.  When  drunk  in  such  fluids  as  beer,  or  di- 
luted liquors,  the  resulting  disturbances  of  the  system  are  attribu- 
table rather  to  other  ingredients. 

Laymen  are  usually  more  willing  to  ascribe  obesity  to  supposed 
excessive  consumption  of  fluids  than  to  overeating.  They  often  say 
that  they  supposed  water  was  "  fattening."  It  is  so  only  in  the  sense 
that  it  promotes  tissue  change  or  metabolism  and  washes  away 
waste  matter,  not  in  the  sense  that  it  is  itself  a  storage  substance,  as 
fat  is. 

Deprivation  of  Water.  Water  Starvation.— When  water 
is  withheld  from  the  system  for  a  considerable  length  of  time  its 
absence  is  first  apparent  in  the  secretions  and  excretions,  and  next 
in  the  various  tissues  of  the  body,  the  last  of  all  being  those  of  the 
nervous  system.  More  than  ten  or  twelve  hours  of  abstention  from 
drinking  produces  uncomfortable  thirst,  and  one  or  two  hours  of 
violent  exercise  may  do  so  at  once. 

Continued  deprivation  of  water  causes  the  blood,  by  virtue  of  its 
self-regulating  power,  to  withhold  fluid  from  the  kidneys  and  diges- 
tive glands.  The  digestive  secretions  therefore  become  less  fluid,  of 
more  intense  reaction,  and  greatly  diminished  in  quantity.  The 
mucous  surfaces  become  dry,  and  the  dryness,  owing  to  the  passage 
of  air  and  the  consequent  evaporation,  is  first  felt  in  the  mouth  and 


36 


FOODS  AND   FOOD   PREPARATIONS. 


pharynx.  The  diminution  in  the  digestive  secretions,  as  well  as  their 
altered  strength,  interferes  with  or  retards  their  normal  action  upon 
the  ingesta.  The  proper  movement  of  the  food  in  the  stomach  and 
intestines  is  retarded  by  its  greater  solidity  and  by  the  increased 
friction  of  the  mucous  walls,  especially  in  the  lower  bowel.  Consti- 
pation therefore  results.  The  absorption  of  fluid  through  the  walls 
of  the  alimentary  canal  is  retarded,  and  nutrition  suffers  in  conse- 
quence. Meanwhile  the  blood,  to  maintain  its  normal  character,  re- 
absorbs water  from  the  lymph  spaces  and  different  tissues  of  the 
body.  The  muscles  and  other  structures  become  dry  and  diminish 
in  volume.  Emaciation  results,  which  quickly  reaches  an  extraordi- 
nary and  painful  degree.  The  mind  dwells  on  water  constantly,  and 
taste  is  diminished.  Finally,  the  nervous  system  suifers  from  dry- 
ness and  various  nervous  symptoms  ensue,  so  that,  in  addition  to 
extreme  muscular  weakness  and  prostration,  there  may  be  delirium, 
and  finally  coma  and  death. 

Thirst. — As  far  as  the  individual  is  concerned,  the  suffering  from 
deprivation  of  water  is  mainly  confined  to  the  sensations  of  thirst 
and  dryness  of  the  mouth.  Thirst  is  commonly,  and  somewhat  er- 
roneously, referred  to  the  mouth  and  the  pharynx.  It  is  true  that 
the  mucous  membrane  in  these  regions  becomes  dry  when  water  is 
withheld,  but  thirst  may  be  also  keen  when  these  surfaces  are  abun- 
dantly moist.  The  sensation  is  the  result  chiefly  of  the  expression 
through  the  nervous  system  of  the  need  of  the  body  tissues  in  gen- 
eral for  fluid,  and  it  is  referred  to  the  mouth  and  throat  from  force 
of  habit,  which  associates  the  act  of  swallowing  fluid,  and  the  use  of 
certain  muscles  in  that  process,  with  the  subsequent  relief  of  thirst. 
In  support  of  the  above  statement  is  a  fact  that  I  have  several  times 
witnessed  in  patients  having  a  gastric  fistula  made  in  consequence  of 
oesophageal  stenosis,  or  in  patients  nourished  wholly  through  nu- 
trient enemata,  that  the  sensation  of  thirst  referred  by  them  to  the 
mouth  is  immediately  relieved  by  the  injection  of  water  into  the 
stomach,  or  of  salt  and  water  into  the  rectum. 

It  is  asserted  that  shipwrecked  sailors  in  open  boats  have  relieved 
their  thirst  by  immersing  their  bodies  in  salt  water.  A  very  little 
water  is  possibly  absorbed  under  these  conditions  through  the  skin. 
Ordinarily,  however,  the  skin  is  not  capable  of  absorbing  fluid  of 
any  kind  to  a  practical  extent,  but  immersion  in  water  prevents 
evaporation  from  the  surface  of  the  body,  and  by  saving  its  loss  in 
that  direction  lessens  thirst.  Sucking  a  slice  of  lemon  or  drinking 
water  acidulated  with  a  few  drops  of  lemon  juice  or  vinegar  some- 
times allays  thirst  better  than  plain  water.  The  same  may  be  said 
of  barley  and  oatmeal  waters.  Lemon  juice  and  ice  is  another 
remedy.  Bitartrate  of  potassium  or  very  weak  brandy  may  be  used 
for  the  same  purpose,  and  is  sometimes  more  satisfying. 


SALTS. 


37 


On  one  of  the  late  arctic  expeditions  which  have  resulted  so  dis- 
astrously the  men  had  no  water  for  two  months,  but  ate  snow,  hav- 
ing no  fuel  to  spare  to  melt  it. 

"  Hot  water,  as  hot  as  can  be  sipped,  quenches  thirst  much  better 
than  cold,  which  is  of  little  avail  "  (Balfour). 

Glycerin  and  water  is  often  used  to  allay  thirst  by  rinsing  the 
mouth.  The  glycerin,  being  viscid,  coats  the  surface  of  the  mucous 
membrane  and  prevents  to  some  extent  the  drying  by  evaporation, 
but  it  is  hygroscopic  and  tends  to  abstract  water  if  used  too  strong, 
and  practically  it  is  of  little  service. 

When  it  is  undesirable  to  give  water  by  the  mouth,  thirst  may  be 
relieved  by  injection  of  salt  and  water  beneath  the  skin  (see  Hypo- 
dermoclysis)  or  into  the  rectum. 

Thirst  may  be  controlled  somewhat  when  it  is  desirable  to  re- 
strict the  fluids  ingested  by  giving  small  doses  of  opium  (Riegel). 
It  may  be  that  part  of  the  benefit  derived  from  this  drug  in  the 
treatment  of  diabetes  is  due  to  its  controlling  this  symptom.  It  is 
taken  sometimes  by  professional  fasters,  who  aim  to  abstain  from  all 
food,  and  from  as  much  drink  as  possible.  The  latter  is  done  be- 
cause without  food  water  tends  to  promote  tissue  waste  too  rapidly, 
and  loss  of  strength  would  be  more  rapid  upon  no  food  and  an  ex- 
cess of  water  than  upon  no  food  with  water  in  great  moderation. 

Temperature  of  Drinking  Water. — Water  is  drunk  at  various 
temperatures  from  that  of  melting  ice  to  iio°  or  112°  F.  It  is  some- 
times stated  that  the  temperature  of  water  influences  digestion,  but 
the  extent  to  which  it  does  so  is  much  exaggerated.  Very  cold 
water  drunk  quickly  in  large  amount  is  said  to  contract  the  stomach 
wall  and  stimulate  the  heart  action.  Lehman  says  that  water  drunk 
at  60"  F.  causes  a  fall  in  the  pulse  rate  and  in  rectal  temperature, 
but  these  observations  lack  confirmation.  This  subject,  as  well  as 
that  of  the  local  action  of  hot  water,  will  be  found  more  fully  dis- 
cussed under  the  heading  Temperature  and  Digestion. 

Ice  is  often  useful  in  the  sick-room,  but  it  should  not  be  given  to 
young  infants.  Cracked  ice  sometimes  soothes  an  inflamed  throat, 
and  occasionally  it  allays  nausea.  It  relieves  thirst  only  temporarily, 
and  this  symptom  may  be  increased  by  its  prolonged  use.  If  too  much 
is  swallowed  it  becomes  lukewarm  in  the  stomach  and  may  be  vomited. 

II.  SALTS. 

Varieties  of  Salts. — The  principal  salts  derived  from  the  food 
are  as  follows: 

Chlorides  of  sodium  and  potassium;  carbonates  of  sodium,  potas- 
sium and  magnesium;  sulphates  of  sodium,  potassium  and  magne- 
sium; phosphates  of  sodium,  potassium,  magnesium,  and  calcium. 
The  majority  of  these  salts  are  held  to  be  unaltered  by  digestive  pro- 


38 


FOODS  AND   FOOD   PREPARATIONS. 


cesses  and  pass  into  the  blood  or  tissues  without  necessary  chemical 
change.  The  reason  for  this  behef  is  the  fact  of  the  readiness  with 
which  they  can  be  obtained,  unaltered  by  chemical  analysis,  from  the 
different  tissues  of  the  body  and  the  urine.  Some  compounds — name- 
ly, the  salts  of  iron  and  salts  of  the  organic  acids — are  ingested  in  very  . 
minute  quantity  arid  their  uses  are  but  vaguely  understood.  Other 
salts,  such  as  the  chlorides,  carbonates,  and  phosphates  of  the  alka- 
lies and  alkaline  earths,  are  taken  in  much  larger  daily  amount  and 
subserve  definite  purposes. 

Uses  of  Salts  in  Food. — The  uses  of  the  salts  derived  from  the 
food  are  summarised  as  follows: 

I.  To  regulate  the  specific  gravity  of  the  blood  and  other  fluids 
of  the  body. 

II.  To  regulate  the  chemical  reaction  of  the  blood  and  the  various 
secretions  and  excretions. 

III.  To  preserve  the  tissues  from  disorganisation  and  putre- 
faction. 

IV.  To  control  the  rate  of  absorption  by  osmosis. 

V.  To  enter  into  the  permanent  composition  of  certain  structures, 
especially  the  bones  and  teeth. 

VI.  To  enable  the  blood  to  hold  certain  materials  in  solution. 

VII.  To  serve  special  purposes,  such,  for  example,  as  theinftiu-'^ 
ence  of  sodium  chloride  on  hydrochloric-acid  formation,  and  that  of 
lime  salts  in  favouring  coagulation  of  the  blood. 

Generally  speaking,  fruits  and  nuts  contain  the  least  quantity  of 
salts,  meats  rank  next,  after  them  vegetables,  and  pulses  and  cereals 
contain  most  of  all  (Chambers). 

Hxcess  of  Salt. — Salts  of  any  kind  when  taken  in  excess  with 
the  food  disagree  with  digestion  in  various  ways.  They  may  prove 
locally  irritant  to  the  gastric  or  intestinal  mucous  membrane ;  they 
modify  the  rate  of  absorption  of  digestive  material,  and  alter  the 
intensity  of  reaction  of  the  different  digestive  fluids.  After  being 
absorbed  in  excess  they  may  interfere  with  the  nutritive  and  chem- 
ical processes  of  the  blood  and  tissues.  Some  persons  acquire  a  salt- 
eating  habit  and  partake  too  freely  of  common  salt  with  the  food, 
with  the  result  of  the  production  of  more  or  less  dyspepsia  or  some 
of  the  symptoms  above  indicated.  Too  much  salt  in  the  food  pro- 
duces thirst,  and  may  even  stimulate  a  craving  for  strong  drink. 

Lime  salts  and  phosphates  when  taken  in  food  or  drinking  water 
in  large  quantities  for  several  weeks  or  months  tend  to  cause  the 
deposit  of  calculi  and  concretions,  such  as  gallstones,  renal  or  vesi- 
cal stones,  etc. 

Deprivation  of  Salt. — Continued  deprivation  of  any  one  of  the 
common  salts,  so  long  as  others  are  furnished  in  reasonable  abun- 
dance in  the  food,  does  not  result  seriously.     If,  however,  all  the  salts 


SALTS. 


39 


are  reduced  in  quantity,  or  if  they  are  entirely  excluded  from  the 
diet,  the  system  very  soon  begins  to  evince  signs  of  malnutrition. 
This  is  readily  accounted  for  by  referring  to  the  uses  of  salts  above  de- 
scribed. Animals  or  men  deprived  of  salts  for  a  long  time  suffer  great- 
ly from  indigestion  and  from  lack  of  bodily  nutrition.  The  body  may 
not  diminish  in  weight,  but  the  tissues  become  "  flabby,"  the  muscles 
feeble,  the  mind  stupid  and  dull,  the  nutrition  of  the  skin  is  altered, 
it  becomes  dry,  and  there  is  falling  out  of  the  hair.  Eventually,  in 
animals  with  salt  starvation  death  occurs  in  from  six  to  eight  weeks 
from  progressive  bodily  weakness  and  inanition — a  condition,  prac- 
tically, of  marasmus. 

Young  infants  who  do  not  obtain  sufficient  salts  of  lime — i.  e.,  if 
fed  upon  proprietary  "infant  foods'*  instead  of  good  milk — become 
rhachitic;  their  bones  ossify  slowly  and  bend  into  deformities.  Such 
children  are  sometimes  given  hypophosphite-of-lime  biscuits  to  sup- 
ply the  deficiency,  but  they  should  be  properly  fed  upon  milk  (see 
Rhachitis). 

Sodium  Chloride. — Sodium  chloride,  or  common  table  salt,  is  by 
far  the  most  important  and  valuable  salt,  and  is  used  in  the  largest 
amount.  It  has  long  been  a  symbol  of  wisdom  and  hospitality  in 
the  East.  It  forms  the  chief  salt  in  the  composition  of  the  blood 
(60  per  cent),  and  enters  into  the  structural  formation  of  all  the  tis- 
sues and  secretions  of  the  body  in  greater  or  less  quantity,  with  the 
single  exception  of  the  enamel  of  the  teeth.  It  is  estimated  that  the 
quantity  which  may  be  daily  appropriated  from  the  food  is  about 
fifteen  grammes.  Salt  slightly  stimulates  the  renal  secretion,  which 
in  turn  leads  to  thirst  and  to  drinking  more  fluid,  which  promotes 
interchange  in  the  juices  of  the  body.  It  also  excites  thirst  more 
directly. 

Common  salt  stimulates  the  appetite  and  influences  beneficially 
the  gastric  secretion.  It  not  only  furnishes  the  chlorine  for  hydro- 
chloric acid,  but  seems  to  act  locally  in  the  stomach  by  promoting 
this  secretion  as  well  as  the  conversion  of  pepsinogen  into  active 
pepsin.  Cohn  and  Voit  have  proved  that  the  absence  of  salt  from 
the  diet  completely  checks  the  production  of  hydrochloric  acid  in  the 
stomach. 

There  are  some  few  tribes  of  flesh-eating  men  who  do  not  add 
salt  to  their  food,  relying  for  their  needs  upon  what  they  derive 
from  the  food  itself.  This  supply  is  therefore  sufficient  to  maintain 
life.  In  fact,  as  a  rule,  man  derives  enough  salt  from  the  compo- 
sition of  his  food  to  supply  the  tissues  and  juices  of  the  body,  and 
the  additional  quantity  which  he  takes  as  table  salt  is  mainly  of  serv- 
ice as  a  condiment,  to  give  agreeable  flavour  to  a  mixed  diet  and  to 
sharpen  the  appetite.  The  excess  of  salts  in  general  is  promptly 
eliminated  in  the  urine. 


40 


FOODS   AND   FOOD   PREPARATIONS. 


In  most  men  and  many  of  the  higher  mammalia  the  craving  for 
sodium  chloride  is  instinctive.  Stanley  records  in  In  Darkest  Af- 
rica instances  where  savages  are  accustomed  to  travel  many  hun- 
dreds of  miles  under  great  difficulties  to  obtain  a  coveted  supply 
of  salt. 

Herbivorous  animals  are  even  more  dependent  upon  salt  than  are 
carnivores;  cattle  and  sheep,  for  example,  must  be  given  salt  in  ad- 
dition t6  that  contained  in  their  food  in  order  to  be  maintamed  in 
the  best  condition. 

Overdoses  of  salt  cause  diarrhoea  and  even  gastro-enteritis,  and 
excite  irritation  of  the  nerves  of  the  throat. 

.  Large  doses  of  salt  have  sometimes  been  given  in  the  treatment 
of  pleurisy  with  the  view  of  increasing  the  density  of  the  blood  and 
causing  reabsorption  of  the  pleuritic  fluid  by  promoting  osmosis 
towards  the  vessels.     This  treatment  has  not  met  with  success. 

Almost  all  vegetables  contain  less  sodium  chloride  than  does  milk, 
the  food  of  the  young  growing  animal,  although  many  of  them  have 
more  potassium. 

Sodium  chloride  is  of  great  service  as  a  preservative  of  foods, 
either  used  as  a  brine  in  pickling,  corning  beef,  etc.,  or  in  solid  form 
to  dry  and  keep  meat  and  fish  from  decomposition. 

Potassium  Salts. — Next  in  importance  to  sodium  chloride  ranks 
potassium  chloride,  which  is  the  predominant  salt  of  the  muscles,  and 
which,  like  sodium  chloride,  is  a  common  ingredient  of  nearly  all  the 
tissues  and  fluids.  The  acid  and  neutral  carbonates  and  phosphates 
of  sodium  and  potassium  are  chiefly  important  in  regulating  the  re- 
action of  the  digestive  secretions  and  the  urine. 

Calcium. — The  salts  of  calcium  are  chiefly  of  value  from  their 
constituting  a  large  percentage  of  the  composition  of  the  bones  and 
teeth,  as  well  as  a  smaller  percentage  of  many  other  tissues  of  the 
body.  Their  presence  seems  to  be  associated  constantly  with  cell 
growth  and  development.  The  carbonate  is  often  found  with  the 
phosphate  of  lime,  but  in  less  quantity.  The  occurrence  of  cretinism 
has  been  in  part  attributed  to  an  excess  of  lime  salts  in  the  food, 
more  especially  the  drinking  water;  but  this  theory  is  not  to  be  ac- 
cepted without  question.  The  disease  often  occurs  independently  of 
such  cause,  and  it  is  by  no  means  always  prevalent  in  lime-water 
areas. 

Young  growing  animals  contain  a  larger  percentage  of  earthy 
salts  than  do  older  ones.  Deposits  of  salts  of  lime  occur  in  old 
abscesses,  tubercular  concretions,  tartar  on  the  teeth,  atheromatous 
blood  vessels,  the  arcus  senilis  of  the  cornea,  and  as  calculi. 

Phosphorus. — Phosphorus  is  derived  from  phosphates  in  meat 
and  its  contained  blood  which  is  eaten,  as  well  as  from  vegetables. 
It  enters  into  the  composition  of  the  bones,  muscles,  blood,  etc. 


ANIMAL   FOODS.  ^^ 

Sulphur. — Sulphur  is  derived  from  sulphates  contained  princi- 
pally in  fibrin,  egg  albumen,  the  casein  of  milk,  and  from  such  vege- 
tables as  corn,  turnips,  cauliflower,  and  asparagus. 

Iron. — The  iron  of  the  body  is  found  in  the  blood  pigment,  where 
it  amounts,  all  told,  to  a  third  of  an  ounce.  It  is  also  present  in  mi- 
nute traces  in  other  pigments. 

Its  chief  source  is  from  the  blood  of  animals  which  is  cooked  with 
their  meat.  It  is  also  derived  from,  and  it  may  be  taken  with,  cha- 
lybeate waters. 

Vegetable  Acids. 

The  common  organic  or  vegetable  acids — citric,  tartaric,  malic, 
etc. — are  derived  from  fresh  vegetables  and  fruits,  in  which  they  exist 
usually  in  combination  with  the  bases  Ca,  Na,  K,  etc.  They  are 
indispensable  articles  of  food,  for  when  absorbed  they  form  carbon- 
ates, which  aid  in  maintaining  the  alkalinity  of  the  blood.  Prolonged 
deprivation  of  them  usually  results  in  the  condition  of  scurvy. 

III.  ANIMAL  FOODS. 

Animal  foods  contain  much  nutritive  matter  in  a  more  or  less 
concentrated  form  which  exists  in  practically  the  same  chemical 
combination  with  the  body  itself.  They  leave  comparatively  little 
residue,  being  quite  thoroughly  digested.  They  are  agreeable  in 
flavour,  and  they  hold  salts,  including  iron,  which  are  of  special  value 
as  force  producers.  They  are,  however,  inferior  to  starches  in  this 
property  unless  a  good  deal  of  fat  be  incorporated  with  them. 

The  varieties  of  animal  foods  will  be  described  under  the  head- 
ings milk,  eggs,  meat,  fish,  gelatin,  fats. 

Milk. 

The  milk  of  several  animals,  such  as  cows,  goats,  asses,  mares, 
and  camels,  may  be  used  for  food,  but  in  this  country  very  little  other 
than  cows'  milk  is  employed.  The  varieties  of  milk  differ  slightly  in 
chemical  composition,  odour,  and  taste,  but  they  all  contain  the  ele- 
ments which  are  necessary  for  the  maintenance  of  life  in  fairly  eco- 
nomical proportion,  so  that  for  infants  they  constitute  a  "  complete  " 
food  which  fully  meets  the  requirements  of  the  growing  body,  and  in 
adults  they  will  sustain  life  comfortably  for  many  months. 

For  these  reasons  milk  ranks  among  the  most  important  of  all 
foods,  and  it  is  necessary  to  determine  to  what  extent  it  should  be  in- 
troduced into  ordinary  diet.  A  pint  of  milk  may  be  said  to  represent 
approximately  the  nutrition  contained  in  six  ounces  of  beef  or  mut- 
ton. Although  it  furnishes  so  useful  a  food,  milk  is  by  no  means 
essential  to  a  diet  designed  for  increasing  bodily  strength,  and  it  is 
usually  omitted  from  the  m/nu  of  athletes  in  active  training. 


42 


IFOODS   AND   FOOD   PREPARATIONS. 


Milk  taken  alone  constitutes  an  insufficient  diet  for  adults  in 
health,  for  to  obtain  the  requisite  18.3  grammes  of  nitrogen  2,905 
grammes  of  milk  only  are  needed,  against  4,652  which  must  be  taken 
to  obtain  the  necessary  328.9  grammes  of  carbon  (Bauer)  (see  Force 
Production,  page  7). 

Adults  who  are  able  to  eat  any  kind  of  food  usually  maintain  their 
health  in  better  condition  by  abstaining  from  milk  except  as  used  for 
cooking  purposes,  inasmuch  as  it  makes  many  persons  "  bilious"  to 
drink  it,  and  produces  constipation,  particularly  when  taken  in  excess 
with  other  foods. 

Sir  Henry  Thompson,  in  condemning  the  excessive  drinking  of 
milk  by  persons  in  good  health  who  are  at  the  same  time  eating  large 
meals  of  meat,  says:  "It  is  altogether  superfluous  and  mostly  mis- 
chievous as  a  drink  for  those  who  have  reached  adult  age  and  can 
digest  solid  food."  There  are,  however,  many  diseases  in  which  a 
partial,  or  for  a  time  an  exclusive,  milk  diet  is  to  be  recommended. 

Milk  in  considerable  quantity — i.  e.,  equal  to  one  third  or  one  half 
the  total  amount  of  food  consumed — is  often  highly  desirable  in  such 
diseases  as  phthisis  and  anaemia. 

Hxclusive  Milk  Diet. — An  exclusive  milk  diet  is  usually  desir- 
able in  the  following  conditions  and  diseases : 

1.  In  infancy  for  the  first  year,  and  sometimes  for  the  first 
eighteen  months. 

2.  All  acute  diseases  of  young  children. 

3.  Typhoid  fever. 

4.  Acute  Bright's  disease,  and  sometimes  in  chronic  nephritis. 

5.  Acute  pyelitis. 

6.  Chronic  gastric  catarrh. 

7.  Gastric  ulcer  and  carcinoma, 

8.  Neurasthenia. 

A  milk  diet  is  so  easy  to  prescribe,  so  cheap,  and  so  easily  pro- 
curable, that  it  is  always  the  first  resort  of  those  who,  from  indiffer- 
ence or  lack  of  knowledge  of  the  first  principles  of  dietetics,  are 
unwilling  or  unable  to  take  pains  to  study  the  peculiarities  and 
needs  of  the  individual  case.  It  is  an  easily  measured  food,  and  it 
becomes  a  routine  practice  in  hospitals — where  almost  always  more 
attention  is  awarded  to  medication  than  to  diet — to  order  milk  diet 
for  all  cases  that  are  not  at  the  convalescent  or  full  house  table,  aud- 
it is  doubtless  a  safe  side  to  err  upon,  but  it  is  by  no  means  always 
the  best  that  can  be  done  for  the  patient. 

An  exclusive  milk  diet  in  time  becomes  monotonous  and  weari- 
some to  most  adults,  and  may  produce  dyspepsia,  constipation,  and 
interfere  with  the  functional  activity  of  the  liver.  Aside  from  nausea, 
which  the  continued  use  of  milk  may  excite,  a  positive  loathing  for 
the  taste  of  it  is  apt  to  be  developed,  unless  the  regimen  is  modified 


ANIMAL   FOODS. 


43 


by  occasional  variation.  This  is  a  matter  of  considerable  impor- 
tance in  feeding  patients  suffering  from  typhoid  fever,  chronic 
Bright's  disease,  chronic  gastric  catarrh,  and  other  affections  for 
which  milk  diet  is  often  prescribed ;  for  if  other  substances  are 
substituted  from  time  to  time  in  small  amounts,  while  milk  is  still 
retained  as  the  chief  food,  it  may  be  continued  as  such  for  a  much 
longer  time.  On  seeking  the  cause  for  the  disagreement  of  milk,  it 
is  found  in  the  fact  that  it  contains  too  large  a  proportion  of  nitro- 
genous material  as  compared  with  the  hydrocarbons,  so  that,  in  order 
to  obtain  sufficient  of  the  latter,  an  excess  of  proteid  is  ingested, 
which  interferes  with  normal  digestion. 

For  a  man  in  health  a  pure  milk  diet,  as  Ewald  says,  is  "  slow 
starvation."  If  kept  too  long  upon  it,  he  develops  a  condition  akin 
to  scurvy  (see  Scurvy,  page  668).  This,  however,  does  not  invariably 
follow  in  disease,  and  J.  K.  Mitchell  refers  to  a  patient  with  diabetes 
and  nephritis  who  lived  upon  milk  alone  for  seven  years,  and  kept 
in  active  business. 

Infants  and  children  tire  of  milk  less  easily  than  adults.  Since 
the  adult  needs  twenty-three  ounces  of  water- free  food  per  diem  to 
maintain  healthful  equilibrium,  he  must  consume  nine  pints  of  milk 
at  a  specific  gravity  of  1030  to  supply  it.  The  excess  of  albumin, 
fat,  and  water  which  he  would  then  obtain  is  wasteful  for  him, 
although  it  is  good  for  the  young.  But  in  illness  life  is  comfortably 
maintained  upon  a  smaller  quantity  for  a  few  weeks,  and  in  typhoid 
fever  four  or  five  pints  is  an  ample  allowance,  and  it  is  often  better 
to  give  less  (see  Typhoid  Fever,  Dietetic  Treatment).  In  a  case 
of  chronic  Bright's  disease,  if  the  patient  is  not  confined  to  bed,  it 
may  be  necessary  to  give  six  or  seven  pints. 

In  order  to  digest  large  quantities  of  milk  it  must  be  taken  in 
measured  doses  at  frequent  intervals.  In  typhoid  fever,  for  ex- 
ample, from  three  to  five  ounces  may  be  given  every  two  hours.  In 
some  diseases  it  is  best  to  give  two  ounces  every  hour,  in  others  six 
or  eight  ounces  every  three  hours. 

Milk  leaves  no  coarse  waste  residue  in  the  intestine  like  the  indi- 
gestible fibre  of  meat  or  the  cellulose  of  vegetables  and  fruits.  Not- 
withstanding this  fact,  an  exclusive  milk  diet  yields  considerable  bulk 
of  faecal  matter,  and  a  typhoid-fever  patient  living  on  milk  alone  often 
has  daily  evacuations  of  medium  size.  Riibner  found  that  in  health  a 
diet  of  milk  alone  yields  larger  stools  than  either  roast  beef  or  egg 
alone.  Yet  by  weight  the  absorption  of  milk  is  shown  to  be  very 
complete,  and  four  thousand  grammes  of  milk  ingested  by  the  mouth, 
when  perfectly  digested,  yield  but  one  hundred  grammes  of  faeces 
(Riibner).  There  is  a  marked  loss  through  the  faeces  of  the  salts  of 
lime  which  have  been  contained  in  the  milk.  These  facts  explain 
in  part  why  milk  is  so  constipating.. 


44 


FOODS   AND   FOOD   PREPARATIONS, 


"  Milk  Cure.'' — The  "  milk  cure  "  has  been  carried  out  successfully 
by  Pecholier,  Weir  Mitchell,  Karell,  and  others  for  the  treatment  of 
obstinate  hysteria,  hepatic  congestion,  dropsy,  and  various  anomalies 
of  nutrition.  The  patient  is  given  no  food  but  milk,  which  Pecholier 
orders  every  two  hours  in  small  amount,  increasing  the  quantity 
until  three  litres  a  day  are  taken.  Mitchell  commences  with  doses  of 
half  an  ounce  to  two  ounces  every  two  or  three  hours,  and  in- 
creases the  dosage  by  half  an  ounce  until  sixty  ounces  or  more  are 
taken.  If  the  taste  of  milk  is  disagreeable,  coffee,  salt,  or  caramel  is 
added.  If  thirst  is  complained  of,  natural  water  or  Seltzer  water  is 
given.  After  three  or  four  weeks,  rice,  arrowroot,  and  thin  slices  of 
white  bread  are  allowed,  and  after  five  weeks  raw  meat  or  one  or  two 
cutlets.  The  milk,  meanwhile,  is  continued.  After  a  day  or  two  of 
this  treatment,  hunger  and  thirst  are  not  usually  complained  of.  At 
first  the  pulse  is  accelerated,  but  there  is  seldom  any  conspicuous 
nervousness.  The  tongue  is  coated,  the  water  in  the  urine  is  in- 
creased, there  is  obstinate  constipation  (which  must  be  relieved  by 
enemata  or  medicines),  the  stools  are  hard  and  ochre  or  white  in 
colour,  and  a  great  deal  of  epigastric  distress  and  feeling  of  empti- 
ness are  present.  The  arterial  tension  is  lowered  ;  there  may  be 
muscular  prostration.  There  is  loss  of  weight  at  first.  If  the  treat- 
ment is  persevered  in,  at  the  end  of  a  fortnight  there  is  marked 
improvement  in  the  feelings  and  condition  of  the  patient,  and  after 
SIX  or  eight  weeks  the  cure  is  usually  far  advanced. 

Chemical  Composition  of  Milk.— The  chemical  ingredients 
which  make  milk  valuable  as  a  food  are  water,  salts,  fats,  milk  sugar 
or  lactose,  and  albuminous  materials,  chiefly  casein,  with  some 
albumin.  Scheibe  and  Henkel  claim  to  have  found  traces  of  citric 
acid  in  normal  cow's  milk. 

The  published  analyses  of  milk  vary  slightly,  chiefly  in  regard  to 
the  quantity  of  fats  observed. 

The  following  analyses  are  placed  together  for  comparison : 


Wanklyn. 

London  Dairy. 

Bell. 

Leeds. 

E.  W.  Stewart. 

Fat 

3-20 

9- 30 

4.10 
8.80 

4.01 

9-31 

3-75 
8.86 

3.80 
9.20 

Other  solids 

Total  solids 

Water 

12.50 

87.50 

12.90 

87.10 

13-32 
86.68 

12.61 

87-39 

13.00 
87.00 

100.00 

100.00 

100.00 

100.00 

100. CO 

The  London  Dairy  analysis  is  based  upon  the  examination  of 
120,000  samples  of  milk  conducted  by  the  chemist  to  the  dairy  during 
a  period  of  twelve  years.  The  third  analysis  is  by  Dr.  J.  Carter  Bell, 
an  English  public  analyst,  and  the  fourth  is  by  Prof.  Albert  H.  Leeds, 


ANIMAL   FOODS. 


45 


Letheby  stated  that  the  total  quantity  of  solids  in  milk  should 
amount  to  14  per  cent,  which  is  somewhat  too  high  for  the  average. 

Fat — Milk  fat  is  mainly  formed  of  glycerides  of  palmitic  and 
oleic  acid  (VVarington),  the  latter  constituting  about  50  per  cent 
(Ruppel),  with  five  or  six  other  fatty  acids,  such  as  myristic  and 
stearic,  represented  in  minute  quantity. 

While  the  percentage  of  fat  in  milk,  as  shown  by  chemical  anal- 
ysis in  the  above  tables,  is  about  4  per  cent,  that  of  cream  itself  is 
considerably  higher,  but  cream  is  not  pure  fat.  It  is  simply  an  ag- 
gregation of  the  oil  globules  in  a  much  restricted  top  portion  of  the 
milk.  Average  milk  has  8  to  10  per  cent  of  cream.  Alderney  milk 
may  have  as  high  as  20  or  even  30  per  cent.  Good  milk  should  form 
a  layer  of  cream  about  two  inches  and  a  half  thick  as  it  stands  in  a 
quart  bottle. 

The  globules  of  milk  fat  vary  in  size  between  0.0005  ^"*^  0.00005 
inch  in  diameter,  and  the  smallest  do  not  rise  to  the  surface  as  cream, 
for  their  albuminous  coverings  are  proportionately  heavier  (Waring- 
ton). 

Solids  Other  than  Fat. — These  are  as  follows : 


Wanklyn. 

Leeds. 

E.  W.  Stewart. 

Ash 

0.60 
4.40 
4-30 

0.68 
4.42 
3-76 

0.60 

Lactose 

4.55 
4.05 

Albuminoids  

Letheby  gives  the  percentage  of  lactose  as  5.2,  which  is  too  high 
for  the  average. 

Lactose. — Lactose  is  an  important  ingredient  of  milk.  When 
chemically  pure^it  is  hard,  transparent,  white,  and  crystalline.  It  is 
now  obtainable  in  much  purer  commercial  form  than  formerly,  when 
in  addition  to  its  diuretic  effect,  if  given  therapeutically,  it  often  ex- 
cited fermentation  and  even  glycosuria.  It  has  but  a  faintly  sweetish 
taste,  and  in  its  properties  is  allied  to  both  sucrose  and  starch.  Its 
chief  function  in  human  milk  is  to  supply  energy  for  heat  produc- 
tion for  the  infant  whose  muscles  are  not  yet  active  in  developing 
this  force,  and  it  constitutes  about  one  half  of  the  total  solids  of  milk, 
exclusive  of  fat;  but  the  quantity  present  in  cow's  milk  varies  great- 
ly, and,  as  a  general  rule,  it  bears  an  inverse  ratio  to  the  amount  of 
fat  and  casein  present.  It  is  less  liable  than  cane  sugar  to  ferment 
in  the  stomach ;  and  alone  it  is  not  susceptible  to  alcoholic  fermenta- 
tion, but  in  the  presence  of  fermenting  nitrogenous  material  it  is 
converted  into  lactic  acid,  making  the  milk  sour.  It  is  promptly  ab- 
sorbed from  the  alimentary  canal,  not  remaining  over  an  hour  in  the 
stomach. 

Casein  and  Albumin. — The  principal  albuminoid  of  milk  is  casein, 


^6  FOODS  AND   FOOD   PREPARATIONS. 

but  there  are  a  half  dozen  proteids  which  have  been  described,  show- 
ing dirferent  behaviour  on  coagulation,  in  polariscopic  rotation,  etc.- 
There  is  an  albumin  present  called  lactalbumin,  which  is  coagulable 
by  heat  ■  and  forms  the  tenacious  "  scum  "  which  floats  on  top  of 
boiled  milk.  This  albumin  plays  an  important  role  by  surrounding 
the  minute  oil  globules  of  the  milk  and  preventing  them  from  agglu- 
tination— in  other  words,  it  helps  maintain  the  fat  in  permanent  fine 
emulsion.  It  is  contained  in  solution  in  whey.  Traces  of  peptones 
have  also  been  found  in  milk. 

Casein  itself  is  non-coagulable  by  heat,  even  by  boiling,  but  it  is 
coagulated  in  firm  tough  clots  by  acids,  such  as  the  hydrochloric 
acid  of  the  gastric  juice,  and  by  many  organic  acids  which  occur  as 
products  of  malfermentation  in  the  stomach.  Lactic  acid  is  a  com- 
mon agent  in  forming  the  coagulae.  Casein  is  also  coagulated,  but 
less  firmly,  by  the  special  milk-curdling  ferment  "  rennin,"  which  is 
actively  present  in  the  infant  stomach,  and  in  the  third  stomach  of 
the  calf.  Casein  is  present  in  milk  chiefly  in  an  alkaline  form  as  po- 
tassium caseinate,  and  in  conjunction  with  calcium  phosphate. 

Varieties  of  Milk. — Cow's  milk  differs  much  in  quality  accord- 
ing to  the  breed  and  condition  of  the  animal,  quality  of  its  food, 
and  care  bestowed  upon  feeding  and  hygienic  surroundings.  The 
chief  variation  concerns  the  quantity  of  cream  produced. 

The  milk  of  Alderney,  Jersey,  and  Guernsey  cows  has  more  pro- 
teid  than  that  of  ordinary  animals,  and  Alderneys  give  more  fat 
than  longhorns.  Individual  cows  are  apt  to  vary  among  themselves 
and  from  day  to  day  in  the  quantity  of  their  milk,  and  therefore, 
notwithstanding  general  belief,  it  is  a  disadvantage  to  feed  an  infant 
always  upon  the  milk  of  the  same  cow.  More  uniformity  will,  on  the 
average,  be  secured  by  feeding  the  mixed  milk  of  several  animals, 
the  variations  in  the  components  neutralising  each  other. 

^^ Strippings  "  is  the  name  given  to  residual  milk  which  may  be  drawn 
off  shortly  after  the  ordinary  milking  has  been  completed.  Contrary 
to  popular  belief,  it  possesses  no  advantage  as  food  over  the  rest  of 
the  milk,  and  what  little  difference  in  composition  exists  can  be  arti- 
ficially produced.  It  is  richer  in  fat  but  poorer  in  casein  than  the 
milk  first  drawn.  For  infant  use  it  should  be  diluted  with  two  parts 
of  water. 

Human  Milk. — Human  milk  differs  from  cow's  milk  in  several 
important  particulars.  For  this  reason  it  becomes  necessary  when 
infants  are  fed  upon  the  latter  to  so  modify  it  as  to  render  it  more 
digestible  for  them. 

The  important  differences  between  human  milk  and  cow's  milk 
are  that  woman's  milk  is  sweeter  by  one  third  and  contains  little 
more  than  half  as  much  casein.  As  Leeds  says,  the  calf  grows  faster 
and  has  to  manufacture  more  beef  than  the  baby.     It  needs  more 


_/.... 


ANIMAL   FOODS. 


47 


albumin  for  tissue  building.  The  casein  of  mother's  milk,  moreover, 
forms  smaller  coagulae  both  with  rennet  and  in  the  stomach,  which 
are  more  easily  dissolved.  The  normal  reaction  of  human  milk  is 
alkaline.  Cow's  milk  varies  from  faintly  alkaline  to  neutral,  and  it 
often  becomes  acid,  especially  when  the  animals  are  not  pasture-fed. 
There  is  nearly  one  half  per  cent  more  fat,  and  the  globules  exist  in  a 
finer  emulsion  in  woman's  than  In  cow's  milk.  Cow's  milk  appears 
richer,  whiter,  and  more  opaque  than  human  milk. 

These  differences  are  emphasised  by  the  following  comparative 
analyses  by  Leeds  of  average  cow's  milk  and  human  milk  : 


Sound  dairy  milk. 

Human  milk. 

Reaction 

Feebly  acid. 
1029.7 
Always  present. 
3.75  per  cent. 
4.42        " 
3-76        " 
0.68 

Persistently  alkaline. 
1031.3 
Absent. 

Specific  gravity 

Bacteria 

Fats 

4.13  per  cent. 

7.0 

2.0          " 

Lactose 

Albuminoids 

Ash 

0.2          " 

Total  solids 

12.61 

13-33 

It  requires  more  acid  to  precipitate  woman's  milk  than  cow's  milk. 

Giving  a  nursing  woman  an  excess  of  nitrogenous  food  does  not 
increase  the  albuminoid  elements  of  her  milk  nearly  so  much  as  it 
does  the  fats,  while  giving  her  fatty  or  rich  food  in  excess  does  not 
increase  the  cream  or  other  ingredients  of  her  milk — it  may,  indeed, 
diminish  them  by  disordering  her  digestion.  The  nursing  mother's 
diet  must  therefore  be  plain  but  substantial,  especially  in  regard  to 
animal  foods. 

The  following  analyses  illustrate  the  extent  of  possible  variation 
in  good  specimens  of  human  milk  : 

Eight  Human  Breast-milk  Analyses  (C.  Harrington). 
(Infants  all  digesting  well  and  gaining  in  weight.) 


I. 

II. 

III. 

IV. 

v. 

VI. 

VII. 

VIII. 

Fat 

Percent. 
4-37 
6.30 

3-27 
0.16 

Percent. 
3-76 
6.95 
2.04 
0.14 

Per  cent. 
3.16 
7.20 
1.65 
0.21 

Per  cent. 
3.82 
5-70 

i.o3 
0.20 

Per  cent. 
2.96 
5.78 
1. 91 
0.12 

Percent. 
2.09 
6.70 
1.38 
0.15 

Per  cent 
2.02 

6.55 
2.12 
0.15 

Per  cent. 
2.36 

Milk  sugar 

Albuminoids. . . . 
Mineral  matter. . 

7.10 
2.20 
0.16 

Total  solids . . . 
Water 

14.10 
85.90 

100.00 

12.89 
87.11 

12.22 

87.78 

10.80 
89.20 

10.77 
89.23 

10.32 

89.68 

100.00 

10.84 
89.16 

100.00 

11.82 

88.18 

100.00 

100.00 

100.00 

100.00 

100.00 

Prof.  Albert  H.  Leeds  (American  Text-book  of  the  Diseases  of 
Children,  pp.  42,  43)  has  shown  very  convincingly,  by  a  table  of 


^8  FOODS  AND   FOOD   PREPARATIONS. 

analyses  of  milk  from  eighty  women  of  different  nationalities,  ages, 
and  periods  of  lactation,  that  although  "  the  average  amount  of 
nitrogenous  matters  (albuminoids)  is  somewhat  greater  at  beginning 
of  lactation,  the  difference  is  not  very  marked.  .  .  .  There  is  no 
progressive  change  in  the  composition  of  milk  during  lactation,  but 
after  the  function  has  been  normally  established  the  milk  remains 
substantially  the  same  during  the  entire  period.  .  .  .  The  child  ob- 
tains more  nutriment  day  by  day,  but  it  is  by  spontaneously  increas- 
ing the  quantity  according  to  the  best  rule,  which  is  that  of  normal 
appetite,  and  not  by  absorbing  stronger  and  stronger  food." 

Drugs  in  Huitian  Milk. — Many  drugs  are  excreted  through  the 
mother's  milk,  and  it  is  often  the  case,  that  an  infant  is  affected  by 
sucking  such  milk.  It  is  possible  to  act  upon  infants  through  this 
medium,  but  the  strength  of  solution  in  which  the  drug  reaches  them 
is  far  too  uncertain.  An  infant  has  been  killed  by  nursing  from  a 
mother  who  has  taken  an  overdose  of  laudanum  (Fletcher).  Acids 
given  to  a  nursing  mother  may  cause  colic  in  the  child.  Neutral 
salts  loosen  the  bowels,  and  potassium  salts  act  as  diuretics  for 
infants  when  taken  by  the  mother.  Aromatic  oils,  and  probably  all 
volatile  oils,  are  found  in  the  mother's  milk.  The  agreeable  taste  of 
some  of  these  substances  causes  the  child  to  suck  harder,  and  excites 
thereby  a  reflex  stimulation  of  the  mammary  glands  to  further  secre- 
tion. 

Among  other  drugs  which  have  been  determined  in  the  mother's 
milk  after  ingestion  by  the  stomach  are:  Senna,  rhubarb,  scammony, 
sulphur,  castor  oil,  ammonium  salts,  turpentine,  copaiba,  anise,  dill, 
garlic,  wormwood,  and  jalap.  Antimony  passes  readily  into  mother's 
milk,  and  should  be  given  with  caution  to  nursing  women.  Potassium 
iodide,  corrosive  sublimate,  and  other  mercurial  salts,  arsenic,  zinc, 
and  lead,  all  may  be  excreted  in  the  milk  at  periods  varying  from 
four  hours  to  several  days  after  their  administration  and  continue  to 
be  eliminated  for  a  day  or  two  after  the  drug  has  been  withheld. 

Vegetable  acids  give  rise  to  carbon  dioxide  in  milk.  If  nursing 
inothers  partake  freely  of  fresh  fruit  and  green  vegetables  their  milk 
may  gripe  and  purge  their  infants.  Violent  exercise  and  violertt  men- 
tal emotion  are  harmful  to  the  milk. 

Goafs  milk  is  the  least  digestible  and  nutritious  of  milks,  although 
it  contains  the  most  solids.  It  is  scarcely  used  at  all  in  the  United 
States  except  sometimes  by  very  poor  foreigners,  as  it  is  in  Switzer- 
land and  other  mountainous  European  countries,  and  for  some  East- 
ern tribes  it  is  a  staple  variety  of  milk.  Cheese  is  also  made  from  it 
on  a  large  scale.  It  has  a  peculiar  strong  odour  and  taste,  which  are 
disagreeable  to  those  who  are  unaccustomed  to  it,  and  which  are  par- 
tially expelled  by  boiling.  They  are  due  to  a  substance  called  hircin 
or  hircic  acid. 


ANIMAL   FOODS.  .^ 

49 

Goat's  milk  contains  an  excess  of  fat,  and  for  this  reason  is  too 
rich  for  infant  food,  and  gives  rise  to  vomiting  and  diarrhoea.  The 
coagulae  formed  by  it  are  very  tough. 

Ass's  milk  contains  the  least  solids  of  all  the  milks,  and  is  poor 
in  casein  and  fat.  It  has  a  fair  proportion  of  sugar,  more  than  cow's 
milk,  but  less  than  human  milk.  Ass's  milk  is  sweet  and  easy  of 
digestion,  although  it  has  a  tendency  to  cause  diarrhoea. 

Experiments  in  the  feeding  of  children  direct  from  asses  were 
conducted  in  Paris  in  1883  at  the  Hospice  des  Enfans  Assistes.  One 
ass  sufficed  to  nourish  three  infants,  besides  her  own  foal.  The  asses 
were  kept  near  the  ward  and  the  infants  were  brought  to  them  to 
nurse.  Syphilitic  infants  belonging  to  a  class  which  previously  all 
died  were  thus  nursed,  and  70  per  cent  were  saved.  The  experiment 
does  not  seem  to  have  found  favour  elsewhere.  Goats  were  first 
tried,  but  proved  of  no  service  for  direct  nursing. 

Mare's  milk,  like  ass's,  contains  less  proteid  and  less  fat,  but  more 
lactose  than  cow's  milk. 

The  casein  of  mare's  milk  is  intermediate  in  digestibility  between 
human  and  cow's  milk.  Both  ass's  and  mare's  milk  are  used  in  the 
steppes  of  Russia  and  in  Siberia  for  the  manufacture  of  koumiss  (see 
Koumiss,  page  69). 

Milk  Analysis. — An  accurate  analysis  of  milk  requires  much 
skill  and  the  equipment  of  a  well-organised  laboratory,  but  it  is  often 
important  for  physicians  to  be  able  to  judge  for  themselves  of  the 
quality  of  a  food  so  universally  prescribed  by  them,  and  it  is  there- 
fore deemed  appropriate  to  describe  some  of  the  easier  methods  of 
qualitative  examination. 

Reaction^  Colour,  Taste,  Odour. — Good  cow's  milk  should  be  almost 
neutral,  reddening  blue  litmus  paper  but  very  slightly  if  any.  The 
normal  colour  is  white,  but  it  may  be  slightly  yellow,  especially  if  the 
cow  has  been  feeding  in  wheat  fields  (Hind).  The  taste  is  sweet  and 
the  odour  faint  and  fresh.  Bad  milk  often  has  a  bad  odour,  either 
sour  or  derived  from  absorption  from  some  neighbouring  material. 
It  is  often  sour  to  the  taste,  reddens  litmus  paper  strongly,  and  if 
held  to  the  light  in  a  test  tube  or  small  thin  glass  it  may  have  a 
bluish  or  reddish  tinge  and  appear  watery.  It  curdles  in  tough, 
stringy  or  glutinous  yellowish  lumps  of  large  size. 

Estimation  of  Total  Solids. — To  estimate  the  total  solids  of  milk 
several  tests  are  employed.  Their  object  is  to  furnish  data  in  regard 
to  the  nutrient  power  of  the  milk  and  to  detect  adulteration. 

A  common  method  used  by  health  boards  is  to  weigh  and  evap- 
orate five  cubic  centimetres  of  milk  to  dryness  in  a  small,  flat-bot- 
tomed, platinum  crucible  of  a  known  weight.  This  process  takes 
about  an  hour.  The  residue  is  then  dried  for  an  hour  more  at  100° 
F.  and  weighed.  The  milk  dries  in  two  layers.  The  upper  layer 
6 


50 


FOODS   AND   FOOD   PREPARATIONS. 


consists  of  a  thin  film  of  fat,  which  is  dissolved  in  petroleum  and 
benzine.  The  lower  honeycombed  layer  is  then  washed  and  dried' 
and  weighed  again.  The  loss  in  weight  after  removing  the  upper 
layer  represents  the  amount  of  fat  present.  The  soluble  salts  and 
soluble  proteid  are  then  dissolved  out  by  warm  water  and  alcohol 
and  separated.  Ignition  over  a  Bunsen  burner  drives  off  all  organic 
matter,  and  leaves  the  ash,  which  is  again  weighed. 

Another  less  laborious  method  consists  in  the  use  of  an  instru- 
ment called  a  "  lactometer,"  by  which  the  specific  gravity  of  the 
milk  is  taken. 

A  lactometer  is  a  glass  spindle  resembling  a  urinometer,  but  is 
about  fifteen  centimetres  long,  and  it  easily  floats  in  a  quart 
measure.  It  is  graduated  to  measure  the  specific  gravity  from  o° 
(the  water  line)  to  40°.  Milk  in  which  it  floats  at  below  29°  is  almost 
surely  watered,  or  if  it  floats  above  ^s°  the  milk  is  skimmed.  The 
specific  gravity  of  the  milk  being  taken  with  the  lactometer,  the 
amount  of  dilution  is  easily  computed  by  comparing  it  with  the 
normal  standard,  30°.  Suppose  this  specific  gravity  to  be  21°  in  a 
given  case,  then  30  :  21  ;  ^  100  :  70.  That  is  the  normal  gravity,  30 
is  to  the  gravity  of  the  sample  examined  as  100  parts  of  normal 
milk  are  to  the  sample,  or,  in  other  words,  only  70  parts  per  hundred 
of  the  sample  are  milk,  and  30  parts  of  water  have  been  added.  To 
facilitate  the  calculation,  the  space  between  0°  and  40°  may  be  divided 
into  100  parts;  each  division  of  the  second  scale  represents  1°  or  i 
per  cent  of  milk.  Thus,  if  the  lactometer  stands  at  50°  of  this  second 
scale,  there  is  only  50  per  cent  of  milk  in  the  sample. 

There  has  been  much  dispute  regarding  the  lactometer,  on  the 
ground  that  an  excessive  amount  of  cream,  on  account  of  the  light- 
ness of  the  fat,  diminishes  the  specific  gravity  of  a  really  rich  milk. 
On  the  other  hand,  it  is  claimed  that  the  diminished  gravity  is  always 
due  to  increase  in  the  quantity  of  water,  and  that  milk  rich  in  cream 
will  also  contain  less  water,  and  therefore  maintain  the  normal  stand- 
ard. The  matter  has  been  tested  in  the  courts,  and  in  New  York 
city  the  lactometer  test  alone  is  always  sufficient  to  insure  conviction 
in  trials  for  adulteration  of  milk  with  water. 

Sometimes  in  estimating  the  specific  gravity  acetic  acid  is  first 
added  to  precipitate  the  casein,  which  is  removed  with  the  fat ; 
the  specific  gravity  of  the  whey  is  then  taken.  Hassell  claims 
that  the  latter  is  more  constant  than  the  specific  gravity  of  milk 
itself. 

Estimation  of  the  Fat. — To  estimate  the  amount  of  fat  or  cream, 
the  sample  of  milk  is  allowed  to  stand  in  a  cool  place  for  twenty- 
four  hours  in  a  "  creamometer."  This  is  a  simple  glass  tube  twenty- 
five  millimetres  wide  and  twenty-five  centimetres  deep,  which  is 
graduated  in  hundredths  from  above  downward.     It  is  filled  with 


ANIMAL  FOODS. 


51 


milk  to  the  zero  level.  The  cream  rises  to  the  top,  and  the  per- 
centage of  volume  is  read  of¥. 

This  method  is  amplified  by  Marchand's  process,  in  which  a  simi- 
lar graduated  tube  is  employed,  but  the  cream  is  more  completely 
separated  by  means  of  the  addition  of  ether  and  a  little  liquor  sodae. 
Ninety-five  per  cent  alcohol  is  then  put  into  a  flask  with  the  milk, 
and  the  whole  is  vigorously  shaken,  after  which  it  is  allowed  to  stand 
at  130°  to  140°  F.  In  half  an  hour  the  fat  forms  a  distinct  layer  at 
the  top  of  the  graduated  tube.  The  error  by  this  process  is  said  to 
be  less  than  0.3  per  cent. 

The  richness  of  the  milk  in  cream,  or  its  dilution  with  water,  may 
also  be  measured  by  its  opacity.  Five  cubic  centimetres  of  water 
are  placed  in  a  glass  cell,  called  a  "  lactoscope  "  or  "  diaphanometer  " 
(Donne),  with  parallel  sides,  through  which  a  candle  placed  at  a  dis- 
tance of  a  metre  may  be  seen.  More  milk  is  then  added,  drop  by 
drop,  until  the  opacity  of  the  cell  contents  obscures  the  light.  This 
method  is  more  tedious  and  less  accurate  than  the  previous  one. 
Cream  varies  in  specific  gravity  between  i.oio  and  1.024. 

A  simple  method  of  roughly  determining  the  quantity  of  fat  in 
human  milk  is  given  by  Nias.  To  estimate  the  fat,  the  milk  is 
placed  in  a  test  tube,  made  distinctly  alkaline  by  a  few  drops  of 
liquor  potassae,  boiled,  and  left  for  a  few  hours  in  a  warm  place. 
The  fat,  floating  on  the  surface,  is  then  estimated  by  graduations  on 
the  side  of  the  test  tube.  It  is  of  course  necessary  to  use  test  tubes 
of  uniform  calibre  in  making  comparative  tests. 

Estimation  of  Lactose. — The  method  of  quantitative  estimation  of 
milk  sugar  is  the  same  as  that  employed  for  glucose  in  the  urine. 
The  casein  is  first  precipitated  by  acetic  acid.  The  whey  is  filtered 
and  tested  with  Fehling's  copper  solution  or  with  a  polariscope. 
Convenient  tables  are  made  to  facilitate  the  calculation. 

Estimation  of  Albuminoids. — In  the  method  of  Nias  to  determine 
the  albuminoids  the  sample  of  milk  is  placed  in  a  graduated  test 
tube,  as  if  to  estimate  the  cream,  and  after  some  hours  the  super- 
natant fat  is  drawn  off  by  a  pipette.  Acetic  acid  is  next  added  until 
a  strongly  acid  reaction  develops.  The  milk  is  then  boiled.  All 
the  albuminoids  are  precipitated,  and  after  standing  overnight  the 
quantity  may  be  read  off  on  the  side  of  the  graduated  tube. 

MILK   ADULTERATION   AND   IMPURITIES. 

Of  recent  years  it  has  been  discovered  that  a  very  large  propor- 
tion of  infant  mortality  is  traceable  to  the  use  of  impure  milk,  and 
that  many  diseases,  especially  diarrhoeal  disorders  of  summer,  are 
preventable  when  proper  care  is  exercised  to  protect  the  milk  supply. 
The  subject  is  rapidly  claiming  public  attention,  and  suitable  control- 
ling legislation  has  been  already  adopted  in  most  civilised  countries. 


§2 


FOODS  AND  FOOD  PREPARATIONS. 


The  prevention  of  adulteration  and  contamination  of  milk  is  a 
matter  of  vital  importance  from  both  an  economic  and  hygienic 
standpoint.  Children,  who  are  so  largely  dependent  upon  milk,  do 
not  well  tolerate  its  adulteration,  and  milk  is  so  much  used  as  a  raw 
food — perhaps  more  than  any  other  one  article  of  diet — that  its  care- 
ful inspection  in  regard  to  contamination  by  disease  germs  or  adul- 
terants is  imperative,  and  the  constant  vigilance  of  the  health  boards 
of  large  cities  is  required  to  protect  the  public  from  imposition. 

It  is  better  and  simpler,  however,  for  much  of  the  inspection  to 
be  done  at  the  dairy  farms,  and  in  many  parts  of  this  country  the 
State  boards  of  health  are  becoming  alive  to  the  importance  of  this 
matter,  and  the  sale  of  milk  from  diseased  cows  is  prevented  at 
first  hand. 

The  examination  of  milk  requires  the  adoption  of  a  legal  standard 
of  quality.  In  New  York  city  the  Health  Board  depends  chiefly 
upon  the  use  of  the  lactometer  above  described  (see  Estimation  of 
Solids  in  Milk).  In  States  such  as  Massachusetts,  Rhode  Island,  and 
Maine  a  chemical  analysis  is  required  by  law.  The  normal  specific 
gravity  established  is  1.030  (in  New  York,  1.029),  ^"^  the  normal 
average  amount  of  cream  is  8  per  cent  by  volume. 

The  inspection  of  milk  in  all  large  cities  and  towns  is  made  at 
the  railway  stations  or  ferries  where  the  cans  are  received.  The 
examination  is  under  the  direction  of  expert  officers,  usually  mem- 
bers of  the  local  health  board.  It  is  impossible  and  unnecessary  to 
examine  all  the  milk  brought  in,  but  the  officers  make  frequent 
seizures  and  destroy  at  once  all  milk  found  below  the  legal  standard.- 
Milk  sold  in  shops  and  otherwise  must  also  be  occasionally  exam- 
ined, for  its  dilution  and  adulteration  is  very  easy  and  profitable  to 
the  unscrupulous. 

Milk  may  be  altered  by — 

I.  Addition  of  water,  pure  or  impure.     2.  Addition  of  colouring 
.matter.     3.  Addition    of  preservatives.     4.  Addition    of   substances 
used  for  thickening  after  dilution. 

1.  The  commonest  method  of  adulterating  milk,  and  the  one 
often  most  difficult  of  detection,  is  by  dilution  with  water.  If  the 
water  thus  used  is  pure  it  does  no  harm  other  than  to  defraud  the 
consumer;  but  if  impure,  as  it  often  is  when  drawn  from  wells  near 
manure  heaps,  in  barnyards,  or  country  privies,  it  may  prove  fatal. 

2.  If  milk  has  been  much  diluted  it  becomes  pale  and  bluish,  and 
both  milk  and  cream  are  sometimes  artificially  coloured  with  anilines 
or  other  pigments.  This  form  of  fraud  is  less  injurious  to  health 
than  the  others,  for  but  very  minute  quantities  of  colouring  matters 
are  employed.  Annotto  is  the  commonest  dye  used  to  impart  a 
yellow  colour  to  milk,  cream,  and  butter.  It  is  prepared  from  the 
seeds  of  a  tropical  American  tree  {Bixa  orelland).     It  is  detected  by 


ANIMAL   FOODS. 


53 


allowing  the  milk  to  stand  in  a  tall  glass,  when  the  lower  stratum 
will  contain  the  pigment  associated  with  the  casein  instead  of  re- 
maining colourless,  while  the  naturally  yellower  cream  floats  on  top 
(Hird).  The  cow's  food  may  sometimes  colour  the  milk  red  or  pink, 
and  it  may  be  so  stained  by  traces  of  blood,  in  which  latter  case  the 
lower  layers  are  of  deeper  hue  than  the  upper. 

3.  Various  substances  are  added  to  milk  and  its  products — con- 
densed milk,  butter,  cheese,  and  koumiss — to  keep  them  from  souring. 
These  are  usually  sodium  bicarbonate,  borax,  or  boric  acid.  Salicy- 
lic acid  is  less  often  used.  In  small  quantities  they  do  not  affect  its 
taste  or  hurt  the  digestion  of  adults,  but  they  may  be  injurious  to 
infants,  and  their  use  should  never  be  tolerated.  Salicylic  acid  is 
sometimes  put  into  beer  for  a  similar  purpose,  although  this  is  pro- 
hibited by  law.  The  presence  of  boric  acid  is  detected  by  mixing 
one  part  of  milk  with  two  parts  each  of  hydrochloric  acid  and  satu- 
rated turmeric  tincture.  After  drying  on  a  water  bath  and  adding  a 
little  ammonia,  a  dark-blue  colour  appears  which  changes  to  green. 

4.  Both  milk  and  cream,  after  dilution  with  water,  are  sometimes 
thickened  again  with  such  substances  as  flour,  arrowroot,  farina, 
whiting,  chalk,  tragacanth,  or  carbonate  of  magnesia,  which  disguise 
the  natural  blueness  of  the  attenuated  fluid.  Sugar  is  added  to 
raise  the  specific  gravity  of  diluted  skimmed  milk. 

Milk  is  contaminated  or  rendered  unfit  for  use  by — 

I.  Improper  or  poisonous  foods  eaten  by  the  animal.  2.  Poor 
condition  of  the  animal,  due  to  nursing,  worrying,  etc.  3.  Con- 
tamination by  disease  germs  from  the  cow,  4.  Contamination  by 
extraneous  disease  germs,  5.  Souring  and  decomposition.  6.  Ab- 
sorption of  bad  odours. 

1,  The  colour  of  milk  is  aft'ected  by  various  substances  ingested 
by  the  cow;  thus  madder  turns  it  saffron,  rhubarb  makes  it  red  or 
yellow  (Mosler),  and  it  is  coloured  blue  by  some  drugs.  The  colour 
IS  then  uniform  throughout  the  milk,  and  not  superficial  as  in  the 
case  of  the  blue  imparted  by  the  growth  of  fungi,  as  described  below. 

Cows  fed  on  brewers'  swill  or  refuse  of  glucose  factories,  or 
cows  allowed  to  eat  decaying  autumn  leaves,  garlic,  certain  injurious 
meadow  plants,  or  strong-smelling  plants  like  cabbages,  turnips, 
and  onions,  will  give  unhealthy,  strong-smelling,  bad-tasting,  or  de- 
teriorated milk.  Beets  tend  to  make  cow's  milk  acid.  Cows  should 
not  be  given  unclean  water  to  drink.  Offensive  odours  and  tastes 
imparted  to  milk  through  the  cow,  or  by  absorption  from  surround- 
ing substances  (see  6,  p,  57),  are  most  intense  while  the  milk  is 
fresh  ;  whereas  if  due  to  bacteriological  influences,  they  only  become 
apparent  after  some  hours,  and  go  on  increasing. 

2,  The  milk  first  secreted  after  calving  (colostrum)  contains 
more   albumin    than   casein.      It    is   viscid,    turbid,    frothy,  yellow, 


54 


FOODS  AND   FOOD   PREPARATIONS. 


slightly  acid,  and  coagulates  on  boiling.  In  the  cow  colostrum  has 
a  sickly  odoUf,  and  is  purgative  even  when  cooked.  It  remains  so  for 
about  a  month  after  parturition.  Colostrum  corpuscles  may  be 
easily  detected  by  microscopic  examination. 

The  bulling  cow  may  be  highly  nervous  during  ovulation,  and,  as 
a  reflex  consequence,  her  milk  becomes  acid. 

Cows  which  are  teased  and  worried  by  dogs  or  otherwise,  or 
made  to  exercise  too  much,  give  milk  which  sours  easily  and  dis- 
agrees with  infants.  Underfeeding  makes  the  animal  give  inferior, 
watery  milk. 

3.  Cows  suffering  from  certain  diseases  may  transmit  them 
through  their  milk  to  man,  although  this  method  of  infection  is  less 
common  than  that  through  milk  to  which  germs  have  had  access  in 
process  of  handling  or  transportation.  The  principal  diseases  which 
may  be  derived  from  the  cow  through  her  milk  are  tuberculosis  and 
diphtheria. 

The  Massachusetts  Society  for  Promoting  Agriculture,  in  a  report 
lately  issued  on  "The  Infectiousness  of  Milk," confirms  the  fact  that 
milk  from  cows  having  tubercular  udders  is  infectious.  Tubercle 
bacilli  were  also  demonstrated  in  the  milk  of  twelve  out  of  thirty-six 
cows  having  tuberculosis,  but  whose  udders  were  not  affected.  The 
inference  is  drawn  from  the  report  that  3  per  cent  of  the  milk  fur- 
nished to  Boston  is  infected.  It  is  estimated  that  6  per  cent  of  all 
cows  are  tubercular.  Tubercular  milk  is  of  poorer  quality,  thinner, 
and  bluer  than  normal  milk. 

Cases  have  been  reported  of  infection  of  a  nursing  infant  through 
a  tubercular  mother's  milk,  and  calves  are  undoubtedly  so  infected 
through  cows,  but  it  must  be  remembered  that  the  infant  is  much 
exposed  to  infection  by  its  mother's  sputum,  and  may  inhale  dried 
sputum  frt)m  beneath  her  bedclothing  or  within  the  room. 

However,  the  presence  of  tubercle  bacilli  has  been  indubitably 
demonstrated  at  least  a  half  dozen  times  in  human  breast  milk. 
Tabes  mesenterica  and  tubercular  meningitis  in  children  have  been 
caused  by  infected  milk. 

Transmission  of  diphtheria  to  man  through  raw  milk  is  rare,  but 
it  is  stated  by  Power  and  others  that  bovine  diphtheria,  occurring  as 
an  eruptive  disease  of  the  udders,  can  be  conveyed  in  milk.  More- 
over, cows  inoculated  under  the  shoulder  with  diphtheritic  microbes 
exhibit  the  germs  in  the  milk  after  developing  local  lesions  of  the 
udders.  The  New  York  Health  Board  recently  reported  the  dis- 
covery of  the  germs  in  cheese  made  by  a  milkman  in  whose  family 
diphtheria  was  present. 

The  foot-and-mouth  disease  of  cattle  is  transmitted  to  man  if  the 
milk  of  cows  so  affected  be  drunk  without  boiling,  which  destroys 
the  germs  (Bollinger).     This  disease  is  transmitted  even  when  the 


ANIMAL  FOODS. 


55 


milk  is  diluted  ten  times  or  taken  in  coffee  or  tea,  but  adults  must 
drink  a  good  deal  of  it  in  order  to  become  affected.  Butter  and 
cheese  made  from  such  milk  also  carry  the  infection  (Schneider). 
The  foot-and-mouth  disease  diminishes  the  quantity  of  milk  given  by 
the  cow  by  one  half,  and  the  milk  coagulates  too  quickly  and  has  a 
yellowish  colostrum-like  appearance.  If  the  disease  be  severe  the 
milk  separates  into  slimy  coagulae  and  whey,  and,  on  boiling,  curdles 
in  stringy  masses.  In  other  cases  the  taste  is  acid,  and  on  standing 
twelve  hours  a  yellow  sediment  is  precipitated  with  a  nauseous,  ran- 
cid odour.    The  milk  becomes  infected  from  sores  upon  the  nipples. 

4.  Extraneous  disease  germs  may  find  their  way  into  milk  through 
contact  with  unclean  hands,  or  from  polluted  water  used  for  dilution, 
or  for  washing  cans  and  pans. 

Soxhlet  has  called  attention  to  the  fact  that  if  mother's  milk 
were  sold  like  cow's  milk  after  as  much  careless  handling,  it  would 
produce  as  much  disease.  Calves  have  been  known  to  acquire  diar- 
rhoea when  fed  milk  from  pails,  and  the  animals  were  cured  by  allow- 
ing them  to  suck  the  very  cows  from  which  the  milk  had  been  drawn 
into  the  unclean  pails.  According  to  Sedgwick,  milk  may  contain  a 
million  bacteria  to  the  cubic  centimetre  after  its  journey  from  cow 
to  table. 

Cow's  milk  is  too  often  tainted  with  excrementitious  matter  from 
the  stable  or  cow  yard.  The  cows  lie  upon  foul  bedding,  or  be- 
spatter their  udders  continually  in  barnyard  filth.  Soxhlet  has  said 
that  in  judging  the  quality  of  milk  one  should  consider  "not  so 
much  what  the  cow  fed  on,  as  rather  what  kind  of  cow  dung  the 
milk  contains." 

Freeman  says  :  "  The  most  important  source  of  contamination  is 
undoubtedly  the  dairy,  where  dirty  and  ignorant  methods  are  almost 
universally  employed  not  only  during  the  milking,  but  in-the  subse- 
quent care  of  the  milk.  Delay  in  transportation  affords  time  for  the 
multiplication  of  the  germs  which  have  entered  the  milk." 

Gaffky  reported  three  cases  of  illness  from  drinking  milk  con- 
taminated during  the  milking  of  a  cow  having  haemorrhagic  enteritis. 
.  In  Aberdeen,  in  1881,  three  hundred  and  twenty-two  persons  were 
poisoned  by  bad  water  added  to  milk,  three  of  whom  died. 

It  is  believed  that  syphilis  is  not  conveyed  through  human  milk, 
though  the  infant  may  become  infected  through  abrasions  of  the 
mother's  nipples  (Lee,  Baumler). 

Milk  carelessly  transported  promptly  absorbs  germs  from  the  air 
or  from  unclean  receptacles,  and  it  is  an  excellent  culture  medium 
for  rapid  growth  of  such  germs  as  those  of  tuberculosis,  scarlatina, 
diphtheria,  and  typhoid  fever,  which  may  gain  access  to  it  in  that 
manner. 

When  local  epidemics  of  such  diseases  break  out,  there  should  al- 


0  FOODS   AND   FOOD   PREPARATIONS. 

ways  be  a  thorough  investigation  of  the  sources  of  milk  supply,  and 
a  bacteriological  examination  of  the  milk  itself  should  be  instituted. 
Many  persons  imagine  that  a  chemical  analysis  is  sufficient,  but  this 
is  useless  for  detection  of  disease  germs. 

Severe  epidemics  of  typhoid  fever  have  of  late  years  been  attrib- 
uted to  infected  milk  by  H.  E.  Smith,  at  Waterbury,  Conn. ;  by  L.  H. 
Taylor,  at  Wilkesbarre,  Pa. ;  and  by  Littlejohn,  who  traced  the  origin 
of  sixty-three  cases  to  one  dairy.  No  one  who  is  nursing  a  case  of 
typhoid  or  scarlet  fever  or  diphtheria,  or  who  m  any  way  handles  the 
discharges  or  clothing  of  such  patients,  should  be  allowed  to  touch 
milk  or  milk  receptacles,  much  less  to  milk  a  cow. 

At  Brewster,  N.  Y.,  Miller  reported  twenty-four  cases  of  scarla- 
tina which  occurred  among  those  who  drank  the  milk  supplied  by 
one  dairyman  while  his  daughter  had  scarlet  fever.  The  disease  was 
not  otherwise  prevalent  in  the  town  at  the  time. 

E.  Hart  reported  at  the  Seventh  International  Medical  Congress 
a  series  of  epidemics  in  England  the  origin  of  which  he  had  traced 
to  milk.  Of  these,  fifty  were  of  typhoid  fever,  fourteen  of  scarlatina, 
and  seven  of  diphtheria. 

A  mould,  the  Oidium  lactis,  ox  penicillmm,  and  the  Bacterium  cyano- 
geneum  are  germs  which  produce  a  blue  colour  in  milk  and  sour 
it.  The  mould  also  grows  upon  cream  cheese.  This  colour  appears 
first  upon  the  surface  if  the  milk  be  not  agitated,  and  it  differs 
from  the  uniform  blue  imparted  by  adulteration  with  water,  or  by 
poisonous  plants,  drugs,  etc.  Milk  thus  affected  is  irritant,  and  may 
cause  febrile  gastritis,  stomatitis,  or  diarrhoea. 

Milk  is  coloured  lemon  yellow  by  the  Bacterium  synxanthum 
(Ehrenberg),  and  red  by  chromogenic  fungi. 

The  fungi  and  germs  themselves  do  not  impart  the  colours,  but 
develop  various  anilines — aniline  blue,  fuchsin,  etc. — from  the  casein 
(Schroter). 

"  Clouty  cream  "  is  produced  by  germ  action. 

5.  There  are  ten  different  varieties  of  bacteria  which  are  capable 
of  inciting  lactic-acid  fermentation  (Leeds),  all  of  which  cause  milk 
curdling,  and  some,  but  not  all,  simultaneously  develop  carbonic 
acid  and  alcohol.  Milk  may  be  really  decomposing  although  it  has 
not  yet  coagulated. 

The  first  process,  that  of  the  formation  of  lactic  acid,  is  a  pre- 
liminary to  the  normal  digestion  of  milk,  but  the  second  is  abnormal 
and  interferes  with  it. 

The  Bacilli  acidi  lactici  may  sour  the  milk  before  it  is  ingested,  or, 
like  many  germs,  their  action  may  not  be  apparent  before  swallow- 
ing the  milk,  but  it  begins  immediately  thereafter  in  the  stomach. 

Good,  clean,  uncontaminated  milk  ought  to  keep  fresh  ex- 
posed in   a  clean   room  at  the  ordinary  temperature  of  68°  F.  for 


ANIMAL  FOODS. 


57 


forty-eight  hours  without  souring  and  coagulating.  But  if  the  air  is 
much  warmer,  or  if  the  milk  is  tamted  in  any  manner,  it  will  sour  in 
a  few  hours.  Boiled  milk  keeps  fresh  rather  more  than  half  as  long 
again  as  fresh  milk. 

6.  The  absorbent  power  of  milk  is  strong,  and  it  is  apt  to  acquire 
a  strong  odour  from  substances  kept  in  its  vicinity.  It  may  acquire 
a  bad  taste  at  the  same  time,  or  may  have  the  odour  alone. 

If  left  in  a  refrigerator  with  stale  cheese,  ham,  onions,  decompos- 
ing meat,  etc.,  it  soon  becomes  spoiled  in  this  manner.  Milk  easily 
absorbs  the  odour  of  tobacco  or  of  turpentine  from  fresh  paint,  and, 
in  fact,  the  odour  of  almost  any  volatile  substance.  It  should  never 
be  left  exposed  in  the  sick-chamber  or  in  a  bathroom,  or  near  a  waste 
pipe. 

PROPHYLAXIS   AGAINST   MILK   INFECTION. 

As  a  prophylaxis  against  milk  infection  certain  precautions  are 
necessary,  and  it  should  be  the  duty  of  physicians  to  educate 
public  sentiment  in  regard  to  their  importance  as  a  means  of  restrict- 
ing the  spread  of  infectious  and  dietetic  diseases. 

For  transportation  from  the  country  to  the  city,  milk  is  usually 
taken  from  the  farms  in  forty-quart  tin  cans,  which  should  be  filled 
full  and  tightly  covered  to  prevent  churning  and  souring.  Some 
railways  supply  refrigerator  milk  cars,  which  are  hung  upon  specially 
constructed  springs,  to  prevent  as  far  as  possible  agitation  of  the 
cans.  At  some  dairies  the  milk  is  put,  directly  after  milking,  into 
glass  bottles  previously  sterilised  by  washing  and  steaming,  which 
are  then  tightly  corked.  If  pails,  pans,  or  cans  are  used,  their 
absolute  cleanliness  must  be  insured  by  frequent  careful  washing 
and  by  occasional  scalding  with  hot  water.  This  destroys  germs  or 
ferments  which  would  otherwise  contaminate  the  fresh  milk  and 
soon  sour  it.  The  bottles  are  sealed  and  stamped  "certified  milk  " 
before  being  sent  to  market. 

Many  large  dairies  now  employ  a  physician,  whose  duty  it  is  to 
daily  examine  all  the  cows  and  report  on  their  health,  and  on  the 
hygienic  condition  of  the  stables,  yards,  etc. 

Nothing  is  more  disgusting  than  allowing  the  manure-besmirched 
tails  of  ungroomed  cows  to  contaminate  the  hands  of  milkers,  or  the 
milk  itself,  and  yet  this  is  constantly  happening. 

The  question  of  prophylaxis  is  of  such  universal  interest  that 
the  admirable  rules  formulated  by  Vaughan  are  here  quoted  in 
full: 

"rt.  The  cows  should  be  healthy,  and  the  milk  of  any  animal 
which  seems  indisposed  should  not  be  mixed  with  that  from  the 
healthy  animal. 

''b.  Cows  must  not  be  fed  upon  swill  or  the  refuse  from  brew- 
eries or  glucose  factories,  or  upon  any  other  fermented  food. 


58  FOODS  AND  FOOD  PREPARATIONS. 

"  c.  Milch  cows  must  not  be  allowed  to  drink  from  stagnant  pools, 
but  must  have  access  to  fresh  pure  water. 

"  (/.  The  pasture  must  be  freed  from  noxious  weeds,  and  the  barn 
and  yard  must  be  kept  clean. 

"(f.  The  udders  should  be  washed  and  then  wiped  dry  before 
each  milking. 

"/.  The  milk  must  be  at  once  thoroughly  cooled.  This  is  best 
done  in  the  summer  by  placing  the  milk  can  in  a  tank  of  cold  water 
or  ice  water,  the  water  being  of  the  same  depth  as  the  milk  in  the 
can.  It  would  be  well  if  the  water  in  the  tank  could  be  kept  flow- 
ing, and  this  will  be  necessary  unless  ice  water  is  used.  The  tank 
should  be  thoroughly  cleaned  each  day  to  prevent  bad  odours.  The 
can  should  remain  uncovered  during  the  cooling  and  the  milk  should 
be  gently  stirred.  The  temperature  should  be  reduced  to  60°  F.  or 
lower  within  an  hour.  The  can  should  remain  in  cold  water  until 
ready  for  delivery. 

''g.  Milk  should  be  delivered  during  the  summer  in  refriger- 
ated cans  or  in  bottles  about  which  ice  is  packed  during  trans- 
portation. 

"^.  When  received  by  the  consumer  it  must  be  kept  in  a  clean 
place  and  at  a  temperature  some  degrees  below  60°  F. 

"If  all  the  milk  used  in  the  artificial  feeding  of  infants  could 
be  obtained  and  marketed  with  the  care  demanded  by  the  above 
rules,  milk  infection  would  be  practically  unknown  and  the  steril- 
isation of  the  infant's  food  would  be  unnecessary." 

USES   OF   MILK. 

The  following  are  the  more  important  uses  of  milk  : 

1.  As  an  infant  food. 

2.  As  a  food  for  adults. 

3.  As  a  source  of  special  food  products  and  derivatives,  such  as 
koumiss,  cream,  butter,  and  cheese. 

4.  As  a  diuretic. 

5.  For  its  soothing  effect  on  diseased  mucous  membranes  of  the 
alimentary  canal. 

6.  To  loosen  cough  (when  given  hot). 

7.  As  a  prophylactic  against  lead  poisoning. 

8.  As  a  vehicle  for  the  administration  of  other  foods, 

9.  As  a  vehicle  for  the  administration  of  medicines. 
ID.  For  rectal  injection. 

The  first  three  of  these  uses  are  so  important  that  they  will 
receive  separate  detailed  consideration  (see  Food  for  Infants,  p.  718, 
Adaptation  of  Milk  for  the  Sick,  p.  62,  and  Milk  Derivatives,  p.  81); 
the  others  may  be  briefly  referred  to  here. 

4.  The  diuretic  action   of   milk  in   some  persons  is  very  pro- 


ANIMAL   FOODS. 


59 


nounced,  while  in  others  it  is  not  noticeable.  It  is  due  to  the  two 
ingredients,  water  and  lactose  or  milk  sugar.  The  water  acts  by 
increasing  the  volume  of  blood  and  the  renal  blood  pressure.  The 
lactose  probably  acts  directly  by  stimulating  the  renal  epithelium. 

Lactose  has  been  employed  with  doubtful  success  as  a  diuretic 
in  dropsies  and  some  forms  of  renal  disease. 

The  mineral  salts  and  the  water  of  milk  are  speedily  absorbed 
by  the  mucous  membrane  of  the  stomach,  and  in  some  persons 
this  process  is  so  rapid  that  milk  taken  by  the  tumblerful  into  an 
empty  stomach  has  a  very  decided  diuretic  effect  within  an  hour. 
This  action  may  be  further  promoted  by  drinking  a  cup  of  black 
coffee. 

5.  Milk  is  undoubtedly  soothing  to  the  mucous  membranes  of  the 
alimentary  canal.  It  is  often  the  only  variety  of  food  which  can  be 
borne  by  an  inflamed  or  irritable  stomach  or  in  some  forms  of  intes- 
tinal disease.     It  is  equally  soothing  in  the  rectum. 

6.  A  few  sips  of  hot  milk  or  hot  milk  and  Vichy  will  often  allay 
an  irritable  cough,  and  favour  the  expectoration  of  tenacious  bron- 
chial mucous. 

7.  Milk  is  sometimes  employed  among  type  founders  as  a  prophy- 
lactic against  lead  poisoning.  It  is  claimed  by  Hirt  that  if  a  quart 
or  two  be  drunk  daily,  poisoning  never  occurs. 

8.  As  a  vehicle  for  administration  of  other  foods  for  invalids, 
such  as  egg  albumen,  beef  meal,  meat  juice,  peptonoids,  cocoa,  spir- 
its, etc.,  milk  is  most  useful. 

9.  As  a  vehicle  for  the  administration  of  many  medicines  and 
insoluble  powders,  such  as  calomel,  disagreeable-tasting  drugs,  like 
potassium  iodide,  salicylates,  opium,  etc.,  milk  is  often  very  service- 
able. Sulphonal  given  in  hot  milk  acts  better  than  if  prescribed 
alone. 

10.  Milk  is  employed  in  nutritive  enemata,  alone  or  with  .beef 
juice,  beef  peptonoids,  spirits,  etc.  From  one  to  two  or  more  ounces 
are  given  at  a  time,  after  cleansing  the  rectum.  A  little  laudanum 
may  be  added,  and  a  towel  should  be  held  against  the  perinaeum  to 
aid  in  the  retention  of  the  milk.  When  the  circumstances  admit,  it 
is  advisable  to  pass  a  long  catheter  and  inject  the  milk  through  it  as 
far  as  the  sigmoid  flexure,  while  the  patient  is  supported  upon  the 
hands  and  knees.  The  higher  up  the  milk  is  injected,  the  more  read- 
ily it  is  absorbed,  and  the  circulation  of  the  rectum  is  such,  that 
whatever  ingredients  of  the  milk  are  taken  up  by  the  venous  capilla- 
ries of  the  lower  portion  pass  to  the  vena  cava,  whereas  the  ingre- 
dients absorbed  by  the  superior  haemorrhoidal  or  the  sigmoid  vessels 
are  carried  directly  to  the  vena  porta  and  liver,  where  they  are  as- 
similated more  promptly.  The  lymphatic  capillaries  also  assist  in 
the  absorption. 


60  FOODS  AND  FOOD  PREPARATIONS. 

The  simple  mucous  secretions  of  the  rectum  have  no  proper  di- 
gestive action  upon  milk  (Czerny),  but  they  may  sometimes  cause 
putrefaction  of  its  albuminous  matter,  with  formation  of  tyrosin, 
indol,  etc.  (Marckwald).  It  therefore  facilitates  absorption  to  have 
the  milk  previously  digested  by  pepsin  or  pancreatin.  Patients  hav- 
ing ulcer  or  carcinoma  of  the  stomach,  any  intestinal  obstruction,  or 
irritant  vomiting,  may  be  kept  alive  for  many  weeks  by  the  exclusive 
use  of  nutrient  milk  enemata  (see  Food  Enemata,  pages  375  and  382). 

Attempts  to  get  milk  into  the  circulation  by  rubbing  it  into  the 
skin  and  by  soaking  portions  of  the  body  in  milk  baths  have  proved 
of  no  avail,  for  it  is  not  absorbed  in  that  manner. 

The  intravenous  injection  of  milk  has  been  occasionally  used  in 

cholera  collapse,  post-partum  haemorrhage,  etc.,  and  in  some  few  cases 

it  has  been  found  satisfactory,  but  since  saline  injections  have  proved 

more  efficacious,  those   of   milk   have    been    practically   abandoned. 

Milk  has  also  been  injected  into  the  peritoneal  cavity,  but  without 

much  benefit.     It  has  been  given  hypodermically  in  doses  of  four 

grammes  (Menzel).     One  patient  was  kept  alive  sixty-three  days  in 

this  manner  (Whittaker).     The  milk  thus  injected  is  absorbed  within 

an  hour. 

MILK   DIGESTION. 

Normal  Digestion. — Milk  is  not  altered  in  the  mouth,  but  on 
reaching  the  stomach  the  casein  is  precipitated  by  a  curdling  fer- 
ment, called  rennin.  The  curds,  or  coagulae,  vary  in  size  and  tough- 
ness according  to  the  quality  of  the  milk,  its  degree  of  dilution,  and 
other  circumstances. 

The  gastric  hydrochloric  acid  also  coagulates  milk  by  neutralis- 
ing the  alkali  which  holds  the  casein  in  solution.  Hence  milk  be- 
comes really  a  solid  food  almost  as  soon  as  it  enters  the  stomach. 
In  coagulating,  the  curds  entangle  the  fat  globules,  but  they  are 
soon  dissolved  by  the  ferment  of  the  gastric  juice  (pepsin)  and  con- 
verted into  peptones  or  intermediate  products  called  albumoses. 
The  fat  globules  are  again  liberated,  their  albuminous  envelopes  are 
dissolved,  and  they  coalesce  to  larger  droplets,  in  which  condition 
they  pass  with  the  chyme  into  the  intestine.  The  usual  period  for 
the  digestion  of  milk  in  the  stomach  by  normal  gastric  juice  occupies 
about  three  hours. 

The  salts  and  water  of  the  milk,  and  possibly  to  some  extent  the 
sugar,  are  absorbed  in  great  part  from  the  stomach  wall.  In  proof 
of  this  is  the  fact  that  the  diuretic  action  of  milk  is  often  obtainable 
within  half  the  time  required  for  the  complete  digestion  of  the  al- 
buminoids. When  not  absorbed  by  the  stomach  they  pass  into  the 
intestine  and  are  taken  up  by  the  villi. 

Those  curds  which  are  not  fully  dissolved  by  the  gastric  juice 
may  enter  the  duodenum,  where  their  digestion  is  completed  by  the 


ANIMAL  FOODS.  ^ 

pancreatic  juice.  The  latter  saponifies  the  fat  which  is  absorbed  by 
the  lacteals  of  the  villi. 

Rennin. — Rennet  is  the  name  given  to  an  infusion  of  the  middle 
stomach  of  the  calf  in  brine  which  possesses  special  milk-curdling 
power  which  is  due  to  a  ferment  called  rennin. 

This  milk-curdling  ferment  is  believed  to  be  developed  by  the 
action  of  acids  from  an  antecedent  material  called  zymogen.  Rennin 
is  not  obtainable  from  the  human  stomach  in  large  quantity,  but  it 
undoubtedly  exists  in  the  gastric  juice,  for  pure  pepsin  has  scarcely 
any  curdling  action  upon  milk ;  moreover,  milk  may  curdle  in  either 
neutral  or  alkaline  media  in  which  pepsin  is  inert.  Rennin  is  most 
active  in  an  acid  medium,  but  it  also  works  in  the  alkaline  pancreatic 
juice.  It  possesses  but  little  proteolytic  power.  It  is  believed  to 
exist  more  abundantly  in  the  infant  stomach  than  in  that  of  the 
adult. 

Rennet  may  be  prepared  as  a  powder ;  it  is  sold  by  grocers  in 
alcoholic  solution,  and  when  added  to  milk  which  is  gently  warmed,  a 
light  coagulum  is  formed,  causing  the  milk  to  partially  solidify.  The 
coagulum  contracts  and  squeezes  out  fluid,  which  constitutes  whey. 
The  rennetised  milk  when  flavoured  with  vanilla  or  powdered  cinna- 
mon or  nutmeg  makes  an  agreeable  invalid  food  or  dessert  which  is 
highly  nutritious,  for  it  still  contains  all  the  original  ingredients  of 
milk. 

Abnormal  Digestion. — In  cases  of  indigestion  from  various 
causes  the  curds  may  remain  undissolved  in  the  stomach,  eventually 
irritating  it  and  causing  vomiting,  or  they  may  pass  along  the  intes- 
tine and  be  voided  unaltered  in  the  stools.  This  occurrence  is  more 
frequently  noticed  in  young  infants  than  in  adults. 

Milk  which  disagrees  in  the  stomach  forms  large  and  somewhat 
tough  coagulae  of  casein,  which  are  with  difficulty  dissolved  by  the 
gastric  juice.  Many  substances,  may  be  added  to  milk  which  by 
their  mechanical  presence  will  prevent  this  occurrence,  and  hence 
favour  the  action  of  the  gastric  juice.  Excessive  acidity  of  the  stom- 
ach due  either  to  hypersecretion  of  hydrochloric  acid  or  the  presence 
of  organic  acids,  especially  lactic,  derived  from  the  food  or  fermenta- 
tion processes,  modifies  the  digestion  of  milk  ;  the  lactose  is  altered 
into  lactic  acid  and  the  casein  is  promptly  coagulated.  The  alkaline 
salts  of  milk  are  split  up  and  phosphoric  acid  is  liberated,  and  com- 
plicated fermentative  changes  ensue  which  are  as  yet  imperfectly 
understood.  All  this  causes  more  or  less  gastro-enteric  irritation, 
resulting  in  diarrhoea. 

When  milk  or  cheese  remains  too  long  in  the  stomach  or  intes- 
tine a  further  fermentation  is  excited  accompanied  by  a  neutral  or 
alkaline  reaction,  and  which  results  in  the  final  production  of  butyric 
acid,  and  sometimes  of  other  substances,  such  as  leucin,  tyrosin,  and 


62  FOODS  AND  FOOD  PREPARATIONS. 

ammonia.  But  while  free  hydrochloric  acid  exists  in  the  contents  of 
the  stomach,  the  organic  acids — lactic,  butyric  and  acetic — which  are 
associated  with  milk  fermentation  are  unlikely  to  develop. 

Cow's  milk  may  readily  become  acid  from  alteration  in  the  rela- 
tive amount  of  potassium  biphosphate  and  the  two-thirds  phosphate 
of  potassium.  The  former  if  present  in  excess  hastens  coagulation 
and  an  acid  reaction.  When  warm  the  milk  may  again  become 
alkaline  (Soxhlet,  Heintz). 

These  facts  explain  the  frequent  necessity  of  using  antacids,  such 
as  lime  water  or  sodium  bicarbonate,  with  infant  milk  food.  Mucous 
fermentation  of  the  proteids  makes  the  milk  slimy,  and  it  becomes 
stringy  on  boiling. 

Milk,  according  to  Rubner's  experiments,  yields  more  bulky  resi-' 
due  in  the  faeces  than  either  eggs  or  meat,  yet  its  nutritive  ingredi- 
ents are  very  perfectly  absorbed.  From  8  to  lo  per  cent  approxi- 
mately of  the  solids  of  milk  is  eliminated  in  the  stools. 

ADAPTATION,  OF    MILK   FOR   THE   SICK. 

When  patients  object  to  the  taste  of  milk  alone,  they  can  be  often 
induced  to  take  large  quantities  by  using  it  in  various  combinations 
or  preparations,  or  by  disguising  its  taste.  Many  patients  when  or- 
dered a  milk  diet  positively  assert  that  they  cannot  endure  the  taste 
of  milk,  that  it  always  nauseates  them,  or  that  it  makes  them  bilious 
and  constipated,  and  excites  headache.  They  say,  perhaps,  that  they 
have  faithfully  tried  to  drink  it  before,  and  never  could  tolerate  it ;  but 
scarcely  any  one  individual  has  ever  tried  all  the  different  methods  of 
taking  milk,  and  it  does  not  follow  that  because  it  once  disagreed 
several  years  before  it  will  again.  The  objection  to  the  taste  can 
always  be  overcome,  and  by  a  little  tact  and  perseverance  there  are 
very  few  persons  who  cannot  assimilate  a  more  or  less  exclusive  milk 
diet  for  a  few  days  or  weeks  if  the  milk  is  properly  given  and,  if 
necessary,  artificially  digested  for  them.  Their  previous  unhappy 
experience  is  probably  due  to  having  taken  a  large  dose  of  undiluted 
rich  milk  which  promptly  coagulated,  soured,  and  was  rejected,  ex- 
citing all  the  distaste  which  they  have  treasured  against  it. 

When,  as  in  some  febrile  cases  or  in  acute  Bright's  disease,  a  milk 
diet  is  imperative,  such  patients  should  begin  with  but  a  teaspoonful 
or  two  at  a  time,  repeatmg  it  once  in  ten  or  fifteen  minutes.  If  milk 
is  only  t^ken  slowly  enough  into  the  stomach,  and  mingled  on  the 
way  with  saliva,  like  other  food — eaten  rather  than  drunk — it  is  im- 
possible for  it  to  form  the  large  tough  curds  that  it  does  when  poured 
down  by  the  tumblerful,  like  a  dose  of  salts.  By  degrees  the  patient 
will  be  convinced  of  his  ability  to  retain  it,  and  then  the  dosage  may 
be  increased,  making  such  further  changes  in  the  preparation  of  it 
as  occasion  demands. 


ANIMAL  FOODS. 


63 


In  all  cases  where  there  is  a  tendency  for  milk  to  disagree  it  is 
better  to  give  it  alone  to  the  patient,  by  which  means  various  expe- 
dients used  to  increase  its  digestibility  may  be  better  tested.  Patients 
will  often  digest  both  milk  and  beef  broth  or  milk  and  whisky  when 
these  substances  are  given  at  alternating  intervals  of  one  or  two 
hours,  whereas  if  taken  in  conjunction  they  give  rise  to  dyspepsia. 

The  methods  of  altering  milk  to  suit  the  taste  or  digestive  re- 
quirements are  so  numerous  that  it  will  be  found  convenient  to  group 
them  under  the  following  headings,  although  the  classifications  are 
somewhat  arbitrary  and  here  and  there  may  overlap : 

I.  Methods  of  altering  the  taste  of  milk. 

II.  Methods  of  improving  the  digestibility  of  milk, 

III.  Methods  of  predigestion. 

IV.  Methods  of  sterilisation  and  preservation. 

The  first  method  beguiles  the  patient  into  taking  larger  quantities 
of  milk  without  tiring  of  it ;  the  second  aims  at  preventing  the  for- 
mation in  the  stomach  of  dense  tough  coagulae  which  are  difficult  of 
solution  and  digestion  by  an  enfeebled  gastric  juice;  the  third,  by 
artificial  digestion,  relieves  a  weak  stomach  of  much  labour ;  the  fourth 
prevents  the  accession  of  poisonous  germs  which  would  excite  mal- 
fermentation  and  indigestion. 

I.  Methods  of  altering  the  Taste  of  Milk. 

When  patients  object  to  the  taste  of  raw  milk  or  tire  of  it,  it  may 
be  flavoured  in  a  variety  of  ways.  When  there  is  no  objection  on 
the  score  of  the  nervous  system,  a  teaspoonful  or  two  of  black  coffee 
is  one  of  the  best  means  at  hand,  or  a  little  of  the  extract  of  coffee 
may  be  added.  Very  weak  tea  may  be  preferred.  Caramel  is  an- 
other excellent  flavouring  substance  which  may  be  freely  employed, 
and  ginger  is  also  used.  Other  patients  may  take  a  little  chocolate 
or  cocoa  or  cocoa  nibs  infusion  with  their  glass  of  milk.  Some  pre- 
fer the  addition  of  common  salt  or  a  little  black  pepper.  The  various 
meat  extracts,  fluid  or  solid  (see  Meat  Preparations,  pp.  97-100),  may 
often  be  used  to  advantage.  When  alcohol  is  not  contraindicaied 
many  patients  are  willing  to  drink  much  milk  in  the  form  of  weak 
punches,  or  as  eggnog  in  which  cognac,  whisky,  sherry,  or  rum  may 
be  employed  to  disguise  the  pure-milk  taste. 

The  various  malt  extracts  are  enjoyed  by  some  when  given  in 
milk,  and  their  disagreeable  sweetness  is  thereby  removed.  A  tea- 
spoonful  of  malt  may  be  added  to  a  pint  of  milk  which  is  gently 
warmed  for  half  an  hour,  after  which  it  is  boiled  for  twenty  minutes. 
This  prevents  the  formation  of  large  curds. 

None  of  these  additions  materially  affect  the  nutritive  value  of 
milk,  and  the  occasional  variety  which  may  be  secured  by  experiment- 
ing with  different  substances  will  usually  overcome  all  prejudices.     I 


54  FOODS  AND  FOOD  PREPARATIONS. 

have  often  induced  patients  to  take  large  quantities  of  junket  fla- 
voured with  a  little  spice  (see  Receipts  for  Invalid  Foods),  not  real- 
ising that  they  were  really  eating  only  pure  milk  which  had  passed 
into  the  first  stage  of  digestion.  Patients  who  object  to  milk  be- 
cause they  have  to  drink  so  much  fluid  may  take  the  same  quantity 
as  junket  because  they  can  eat  it  with  a  spoon. 

Much  milk  may  be  smuggled  in  sometimes  in  custards,  gruels,  etc., 
where  there  is  no  objection  to  the  addition  of  other  easily  digestible 

foods. 

II.   Methods  of  improving  the  Digestibility  of  Milk. 

1.  Skimming. 

2.  Boiling. 

3.  Dilution  with  water. 

4.  Dilution  with  alkaline  and  aerated  waters. 

5.  Dilution  with  amylaceous  foods. 

6.  Addition  of  alkalies,  acid  and  other  substances. 

1.  Skimmed  milk  is  the  residue  after  removal  of  the  cream.  It 
contains  water,  90.63  per  cent;  proteid,  3.06  per  cent;  fat,  0.79  per 
cent;  sugar,  4.77  per  cent. 

Skimmed  milk  is  well  digested  by  those  patients  whose  stomachs 
do  not  tolerate  fat  in  any  form,  but  it  will  not  long  support  life,  and 
attempts  which  have  been  made  to  cure  certain  diseases  by  a  skimmed- 
milk  diet  have  signally  failed.  Donkin  advocated  its  use  to  the 
extent  of  six  to  eight  pints  daily. 

It  may  be  employed  temporarily  in  the  milk  cure  for  Bright's 
disease,  dropsies,  and  in  the  treatment  of  neurotic  hysterical  cases. 

Yeo  advises  gouty  subjects  to  drink  ten  minutes  before  each  meal 
a  breakfastcupful  (eight  ounces)  of  hot  skimmed  milk  and  water  with 
the  addition  of  a  small  saltspoonful  each  of  potassium  bicarbonate 
and  salt.  This  is  a  good  means  of  prescribing  an  alkali,  but  there 
is  no  special  advantage  in  the  skimmed  milk. 

2.  ^i9///'«^.— Boiled  milk  exhibits  a  thin  scum  of  albumin  upon  the 
surface  which  entangles  some  of  the  fat  globules,  and  which  is  quickly 
replaced  by  another  after  removal.  This  scum  should  not  be  served 
to  invalids.  There  is  much  discussion  as  to  whether  infants  should 
ever  be  given  raw  cow's  milk,  or  only  that  which  has  been  previously 
boiled,  and  authorities  are  divided  upon  the  matter.  Certainly  in 
most  cases  raw  milk,  if  pure,  provokes  no  harm.  Boiling  the  milk 
arrests  the  development  of  germs  and  fungi  with  which  it  may  have 
become  contaminated,  and  may  thus  prevent  the  spread  of  some 
diseases,  and  it  retards  the  process  of  "  souring  "  and  coagulation. 
Boiling  expels  about  3  per  cent  of  gases — carbon,  nitrogen,  and 
oxygen  (Hoppe) — and  the  loss  of  oxygen  diminishes  the  formation  of 
lattic  acid  and  consequent  souring.  It  alters  the  taste  of  the  milk 
somewhat,  and  makes  it  "  flat."     The  flatness  is  removed  by  agitating 


ANIMAL   FOODS. 


65 


the  milk  with  air  by  pouring  it  back  and  forth  into  two  cups  held 
a  little  distance  apart;  or  it  maybe  removed  by  the  addition  of 
any  aerated  water.  As  a  rule,  boiled  milk  is  preferred  hot,  but  some 
persons  enjoy  it  cold. 

It  is  a  prevalent  idea  that  milk  is  in  general  more  digestible  if 
boiled  than  if  raw,  but  the  results  of  experiment  do  not  wholly  con- 
firm this  view.  Crolas  has  demonstrated  that  boiling  has  no  influence 
upon  either  the  lactose  or  casein,  but  it  slightly  increases  the  free 
soluble  phosphates,  which  he  regards  as  an  advantage. 

Radnitz  found  by  experiment  that  young  animals  absorb  9.4  per 
cent  of  albuminoids  from  fresh  milk,  but  only  5.7  per  cent  from 
boiled  milk,  hence  a  larger  quantity  of  the  latter  must  be  drunk  to 
obtain  the  same  nourishment  which  is  derived  from  raw  milk. 

According  to  Vasilieff,  the  envelopes  of  the  oil  globules  are  altered 
by  heat,  and  he  claims  that  50  per  cent  less  fat  is  absorbed.  This 
seems  too  high  an  estimate  in  view  of  clinical  observation. 

Occasionally  patients  are  made  bilious  and  constipated  by  the  use 
of  boiled  milk  who  digest  it  better  raw.  It  has  decided  advantage  in 
diarrhoeal  diseases,  probably  through  the  absence  of  germs  and  gases. 
In  some  cases  it  may  be  combined  with  thin  chocolate  or  cocoa. 

"Scalded  milk"  is  heated  to  about  150°  F.,  or  practically  "Pas- 
teurised," by  pouring  on  boiling  water.  Thus  treate^d,  milk  remains 
fresh  a  little  longer  than  when  raw. 

3.  Dilution  with  Water. — The  dilution  of  milk  is  accomplished  by 
adding  plain  water,  either  hot  or  cold,  in  the  proportion  of  one  part 
to  two  or  three  of  milk.  If  the  milk  is  exceptionally  rich  in  cream 
and  casein  this  simple  means  will  often  be  sufficient  to  ensure  its 
better  digestion,  for  the  curds  become  both  smaller  and  softer. 

4.  Dilution  with  Alkaline  or  Aerated  Water. — Lime  water  may  be 
added  in  the  proportion  of  two  to  four  or  more  tablespoonfuls  to  each 
tumbler  of  milk,  taken  cold.  In  cases  with  much  acidity  of  the 
stomach  the  lime  water  should  be  mixed  in  the'proportion  of  one  half 
or  even  two  thirds.  When  so  given,  the  taste  of  the  milk  is  so  little 
altered  that  very  few  patients  object  to  it,  and  some  even  find  it 
more  agreeable.  If  diarrhoea  or  nausea  is  present  they  are  controlled 
to  some  extent,  but  on  the  other  hand  constipation  is  increased  by 
the  use  of  lime.  When  the  latter  exists  it  is  better  to  dilute  with 
Vichy  or  carbonic-acid  water.  If  lime  water  is  added  to  neutralise 
the  acidity  of  cow's  milk  the  temperature  of  the  mixture  should  not 
be  raised  above  that  of  Pasteurisation— 160°  to  170°  F.— because  the 
albuminoids  are  more  or  less  decomposed  in  a  boiling  alkaline  solu- 
tion. It  is  better  to  separately  sterilise  the  lime  water  and  add  it 
afterwards. 

Barley  water  may  be  used  as  a  diluent  for  milk  in  diarrhoea,  but 
oatmeal  water  is  better  for  constipation. 
7 


66  FOODS  AND  FOOD  PREPARATIONS. 

Aerated  waters,  such  as  carbonic-acid  water,  alkaline  Vichy, 
bottled  plain  soda,  or  Apollinaris,  may  all  be  added  to  milk,  in  any 
desired  proportion.  In  cases  of  fever  four  ounces  of  a  mixture  made 
with  equal  parts  of  the  diluent  may  be  given  every  hour,  or  eight 
ounces  every  two  hours,  up  to  two  and  a  half  or  three  pints  of  milk 
per  diem. 

Most  of  these  waters  are  best  used  with  cold  milk,  but  for  many 
persons  hot  milk  and  Vichy  make  a  very  agreeable  combination, 
which  is  often  soothing  to  the  obstinate  cough  of  bronchitis.  The 
gaseous  waters  relieve  the  "  flatness  "  of  the  milk,  and  prevent  the 
after-taste  of  it  in  the  mouth,  of  which  many  patients  complain.  The 
mixtures  with  Vichy  and  lime  water  are  especially  serviceable  where 
extreme  irritability  of  the  stomach  is  present  with  a  tendency  to  the 
immediate  rejection  of  all  fluids. 

5.  Dilution  with  Amylaceous  Foods. — Any  form  of  starchy  food — 
flour,  arrowroot,  etc. — serves  as  a  mechanical  diluent  of  milk  by 
mingling  with  it  and  preventing  the  precipitation  of  tough  curds. 
Bread  and  milk,  or  crackers  and  milk,  serve  the  same  purpose,  and, 
being  semisolid,  have  the  further  advantage  that  they  must  be  eaten 
slowly  and  mixed  with  saliva. 

When  infants  vomit  their  milk  it  may  be  temporarily  attenuated 
with  either  barley  water  or  oatmeal  water  added  instead  of  plain 
water,  and  in  the  same  proportion — i.  e.,  one  third  or  one  half.  The 
much-extolled  starchy  "  infant  foods  "  are  less  useful  as  foods  than 
they  are  as  diluents  of  milk,  and  if  used  temporarily  with  the  latter 
object  solely  in  view,  they  are  less  liable  to  produce  rickets,  scurvy, 
gastric  catarrh,  and  other  maladies.  Whenever  amylaceous  substances 
are  selected  to  dilute  milk  for  infants  they  should  first  be  as  far  as 
possible  converted  into  dextrin  and  glucose,  for  gummy  dextrin,  sac- 
charine, or  even  gelatinous  materials  are  all  better  than  crude 
starchy  foods. 

For  adults  a  tablespoonful  of  Mellin's  or  Nestle's  food  dissolved 
in  an  ounce  of  hot  water  and  added  to  a  glass  of  milk  is  both  pala- 
table and  nutritious  in  cases  of  phthisis  or  scrofula. 

6.  Addition  of  Alkalies,  Acid  and  Other  Substances. — The  addition 
of  alkalies  to  milk  renders  it  much  more  digestible  for  some  persons. 
In  hyperacidity  of  the  stomach  or  in  the  presence  of  abnormal  fer- 
mentation alkalies  are  beneficial  as  neutralising  agents.  On  the  other 
hand,  in  cases  in  which  the  gastric  juice  is  very  feeble  or  absent, 
artificially  digested  milk  may  prove  more  serviceable. 

The  admixture  of  alkalies  by  reducing  the  acidity  of  the  gastric 
juice  makes  the  casein  coagulate  more  slowly,  and  in  flocculi  rather 
than  in  large  coagulae. 

Salt  may  be  added — a  saltspoonful  to  the  tumbler  of  milk.  This 
improves  its  digestibility  for  most  persons,  and  renders  it  less  likely 


ANIMAL   FOODS. 


^7 


to  cause  biliousness.  Sodium  bicarbonate,  ten  grains,  or  a  salt- 
spoonful  to  the  tumbler  of  milk,  prevents  malfermentation  in  the 
stomach.  If  hyperacidity  of  the  stomach  exists,  sodium  bicarbonate 
may  prove  better  than  lime  water,  which  is  but  slightly  antacid,  for  it 
contains  but  a  half  grain  of  lime  to  the  ounce.  On  the  other  hand, 
if  the  gastric  juice  is  too  feeble  to  digest  milk  easily,  it  is  sometimes 
a  disadvantage  to  attenuate  it  still  further  with  quantities  of  lime 
water,  and  sodium  bicarbonate  should  be  substituted  to  check  the 
acid  fermentation  of  the  milk  which  the  hydrochloric  acid  of  the 
gastric  juice  fails  to  control.  An  excellent  combination  for  an  irri- 
table stomach  is  made  by  adding  five  or  ten  grains  of  this  salt  and 
two  grains  of  cerium  oxalate  to  each  glass  of  milk.  The  cerium  oxa- 
late has  a  sedative  and  tonic  action  upon  the  mucous  membranes  and 
tends  to  allay  nausea  and  irritation  in  the  stomach. 

Other  substances  sometimes  added  for  gastric  ulcer,  etc.,  are 
sodium  phosphate,  saccharated  lime,  or  a  teaspoonful  of  milk  of 
magnesia  to  the  pint.  A  few  drops  of  liquor  potassae  to  the  pint  of 
milk  are  recommended  by  Bulkley  for  infants  having  eczema. 

Starr  gives  the  following  receipt  for  making  saccharated  lime  for 
diluting  milk  for  infants: 

Slaked  lime,  one  ounce;  refined  powdered  sugar,  two  ounces; 
mix,  triturate,  add  distilled  water,  one  pint.  Shake  occasionally  for 
some  hours  in  a  bottle,  let  stand,  and  siphon  out  the  fluid. 

Roberts  recommends  a  powder  containing  lo  grains  each  of  so- 
dium bicarbonate  and  common  salt,  and  5  grains  of  light  magnesia,  to 
be  added  to  a  tumblerful  of  one  third  hot  water  and  two  thirds  hot 
milk. 

Edes  strongly  recommends  the  addition  of  hydrochloric  acid  to 
milk.  Twenty  minims  of  the  dilute  acid  of  the  pharmacopoeia  are 
stirred  slowly,  drop  by  drop,  into  a  pint  of  milk  which  is  gently 
warmed.  A  fine  flocculent  coagulum  of  casein  floats  in  the  whey, 
and  the  digestibility  of  the  milk  is  improved,  while  a  flat  or  disagree- 
able taste  is  avoided. 

Gelatin. — Gelatin  may  be  employed  in  small  quantity  as  an  at- 
tenuant  of  milk.     Starr  gives  the  following  receipt  for  its  use : 

Soak  a  piece  of  white  gelatin  an  inch  square  in  half  a  cupful  of 

cold  water  for  three  hours.     Put  the  cup  in  a  saucepan  of  water  and 

boil  until  the  gelatin  dissolves.     When  cold  it  forms  a  jelly.     For 

infants  one  or  two  teaspoonfuls  may  be  put  into  each  nursing  bottle 

of  milk. 

III.  Methods  of  Predigestion. 

I.  Peptonised  milk.  2.  Pancreatinised  milk.  3.  Koumiss,  kefir, 
matzoon,  etc. 

I.  Peptonised  Milk.— The  object  of  peptonising  milk  is  to 
complete  a  portion  of  the  digestive  process  outside  of  the  body,  and 


68  FOODS  AND  FOOD  PREPARATIONS. 

thereby  relieve  the  alimentary  canal  of  this  work.  A  great  variety 
of  preparations  of  pepsin,  peptonising  powders,  etc.,  are  offered  in 
market. 

In  general  they  are  pure,  but  they  vary  somewhat  in  rapidity  and 
strength  of  action.  The  powder  may  be  added  some  time  before 
the  milk  is  swallowed,  and  in  this  event  it  can  only  act  in  conjunc- 
tion with  dilute  hydrochloric  acid.  If  added  to  the  milk  at  the  time 
of  swallowing,  the  normal  acid  of  the  gastric  juice  supplies  the 
proper  reaction. 

The  process  of  artificial  peptonising  consists  in  adding  one  of 
the  numerous  preparations  of  pepsin  obtained  at  the  pharmacist's  to 
fresh  acidulated  milk,  and  allowing  it  to  stand  in  a  bottle  immersed 
in  warm  water  at  approximately  the  body  temperature.  A  fermen- 
tation results  in  which  the  casein  is  more  or  less  completely  con- 
verted into  albumoses. 

If  the  process  be  too  long  continued,  further  fermentation  results, 
and  the  milk  becomes  very  bitter.  It  is  therefore  checked  after  a 
few  minutes,  either  by  boiling  the  milk,  which  has  the  effect  of  de- 
stroying the  pepsin,  or  by  keeping  it  upon  ice  until  ready  for  use, 
which  inhibits  the  action  of  the  ferment. 

Either  peptonised  or  pancreatinised  milk  may  be  prepared  in 
quantity  for  use  by  mfants  or  invalids  during  the  day,  and  if  there 
is  an  ice  chest  to  keep  it  in,  it  is  better  to  do  so,  for  then  it  is  more 
uniform  in  composition.  If  ice  is  not  at  hand,  the  preparation 
should  be  freshly  made  for  use  each  time,  otherwise  it  will  become 
bitter  and  spoil. 

2.  Pancreatinised  Milk. — Of  recent  years  the  use  of  pepsin  for 
predigestion  of  milk  has  been  gradually  superseded  by  that  of  pan- 
creatin,  which  acts  best  in  an  alkaline  medium.  This  ferment,  like 
pepsin,  may  be  preserved  almost  indefinitely  in  powdered  form.  Milk 
thus  prepared  is  slightly  yellow  and  less  opaque  than  raw  milk.  The 
process  may  be  conducted  as  follows : 

Add  a  pint  of  fresh  milk  and  a  gill  of  cold  water  in  a  clean  ves- 
sel. Put  in  a  tubeful  of  Fairchild's  "peptonising  powder"  (pancre- 
atic extract  5  grains,  and  sodium  bicarbonate  15  grains),  or  instead 
of  the  pancreatic  extract,  substitute  i  to  2  drachms  of  "pancreatic 
solution  "  made  by  Parke,  Davis  &  Co.,  stir  well,  and  place  in  warm 
(not  boiling)  water  for  half  an  hour  or  until  a  slight  bitter  taste  is 
present. 

This  taste  means  that  fermentation  has  proceeded  far  enough. 
To  allow  it  to  continue  will  make  the  milk  unpalatable,  and  it  is 
almost  impossible  to  disguise  the  bitterness.  Boiling  for  two  or 
three  minutes  stops  all  further  fermentation,  and  the  milk  should 
then  be  placed  on  ice  until  ready  for  use.  Such  milk  will  keep  well 
for  several  hours. 


ANIMAL   FOODS. 


69 


When  used,  serve  alone  cold,  or  add  carbonic-acid  water  to  dis- 
guise the  taste.  For  adults  a  little  coffee  may  be  used  for  the  same 
purpose. 

Pancreatinised  Milk  Gruel. — To  a  pint  of  cold  fresh  milk  add  a 
pint  of  thick  milk  gruel,  boiling  hot.  The  gruel  may  be  made  of 
sago,  pearl  barley,  arrowroot,  oatmeal,  wheat  flour,  or  other  farina- 
ceous food,  according  to  taste.  The  temperature  of  the  mixture 
should  be  about  125°  F,  Add  a  tubeful  of  peptonising  powder  (15 
grains),  and  place  on  the  side  of  the  stove  for  two  or  three  hours, 
avoiding  great  heat.  Then  boil  to  stop  the  fermentation.  Strain, 
and  keep  on  ice  ready  for  use.  The  gruel  disguises  admirably  the 
taste  of  the  milk. 

When  pancreatinisation  is  long  continued  the  casein  is  completely 
digested,  but  the  milk  becomes  too  bitter  for  use. 

Legumin. — Legumin  is  a  vegetable  ferment  which  is  said  to  make 
milk  highly  digestible  for  invalids  by  converting  casein  into  a  sol- 
uble albuminoid.  This  substance,  which  was  lately  introduced  by 
Bovet,  is  also  given  as  a  food  in  doses  of  50  grammes. 

3.  Koumiss. — Koumiss  (spelled  also  koumys  and  kumyss)  is  milk 
artificially  prepared  by  sim.ultaneous  lactic  acid  and  alcoholic  fer- 
mentation. It  was  originally  made  by  the  natives  in  the  steppes  of 
southeastern  Russia  and  other  Eastern  countries  as  a  refreshing  and 
slightly  intoxicating  beverage.  Of  late  years  the  idea  has  been  ad- 
vanced that  it  has  some  beneficial  or  curative  influence  in  chronic 
diseases,  such  as  phthisis,  chronic  bronchitis,  chronic  gastro-intestinal 
catarrh,  and  other  wasting  diseases,  and  as  a  result  the  manufacture 
of  koumiss  has  been  extensively  introduced  into  the  United  States, 
and  at  many  pharmacies  it  can  be  obtained  daily,  freshly  prepared, 
in  pint  or  quart  bottles.  It  is  probable  that  a  large  share  of  the 
benefit  claimed  for  the  native  "koumiss  cure"  is  attributable,  like 
most  "  cures,"  to  the  favourable  climate  in  which  the  patients  live, 
especially  during  the  months  of  May,  June,  and  July,  where  the  air 
is  dry,  clear,  and  aromatic. 

Very  advanced  cases,  and  those  having  active  fever,  may  not  be 
benefited  by  the  "cure,"  but  koumiss  may  be  given  them  at  home. 
Koumiss  is  of  great  service  as  an  easily  digested  food  for  many  cases 
of  obstinate  gastric  irritation  and  severe  vomiting.  In  the  latter  it 
may  be  often  tolerated  when  no  other  nutriment  is  retained.  Its 
uses  are  therefore  various  both  for  infants  and  adults,  and  there  are 
often  cases  in  which  it  agrees  better  than  pancreatinised  milk  or  milk 
prepared  in  any  other  way. 

The  Manufacture  of  Koumiss. — The  manufacture  of  koumiss  may 
be  conducted  by  several  different  processes.  In  southeastern  Russia, 
especially  in  south  Samara,  the  milk  of  a  certain  breed  of  mares  is 
used,  which  is  particularly  rich  in  milk   sugar  but  poor  in  fat  and 


70 


FOODS  AND   FOOD   PREPARATIONS. 


casein,  and  the  animals  are  fed  upon  grasses  which  contain  this  sugar- 
forming  material  in  abundance  (Karrick). 

They  are  light-coloured  animals,  unbroken,  and  are  guarded  with 
greatest  care,  not  being  allowed  dry  food,  such  as  oats  and  hay.  Pas- 
tured among  mountains  contaming  salt  beds,  they  have  access  to 
running  water,  in  which  they  can  bathe  frequently.  They  have  large 
udders  and  abundant  milk  secretion,  which  is  milked  from  four  to 
eight  times  daily.  The  best  koumiss  is  made  in  the  early  summer  by 
pouring  fresh  milk  into  smoked  leather  bottles  or  sabas,  to  which 
is  added  a  little  sour  cow's  milk  or  old  dry  koumiss  ferment.  The 
skins  are  kept  at  a  temperature  about  equal  to  the  body  heat  and 
are  frequently  shaken  for  thorough  mixing,  and  fermentation  is 
allowed  to  proceed  for  three  or  four  days. 

In  the  United  States  koumiss  is  manufactured  from  cow's  milk 
alone  by  the  addition  of  some  artificial  ferment.  Such  home-made 
koumiss  may  be  prepared  as  follows: 

Take  2  teaspoonfuls  of  wheat-flour  dough,  2  tablespoonfuls  of 
millet  flour,  i  tablespoonful  of  honey,  i  tablespoonful  of  beer  yeast. 
Mix  into  a  thin  paste  with  milk.  Place  in  a  warm  place  to  ferment. 
When  fermented,  put  into  a  linen  bag  and  hang  in  a  covered  jar  with 
sixteen  pounds  of  fresh  milk.  Let  stand  for  twenty-four  hours,  or 
until  the  milk  becomes  acid,  at  a  temperature  of  86°  to  90°  F.  Skim, 
decant,  agitate  for  an  hour,  bottle  and  cork  tightly,  protecting  the 
corks  with  wire  fastenings.  Keep  in  a  refrigerator.  Absolute  clean- 
liness must  be  insisted  upon  throughout  all  the  various  manipula- 
tions; otherwise  different  forms  of  fermentation  will  result  (Stange). 

Mare's  milk,  as  compared  with  cow's,  contains  much  more  sugar 
(6  per  cent)  and  less  casein  and  fat  (less  than  3  per  cent)  (Biel). 

Properties. — Koumiss  when  shaken  froths  readily.  It  has,  when 
fresh,  a  slightly  sour  odour,  agreeable  bitter  taste,  and  acid  reaction. 
The  specific  gravity  is  1.018  to  1.029.  During  fermentation  alcohol 
is  developed  from  the  milk  sugar,  which  forms  lactic  acid  and  glucose, 
the  latter  making  alcohol  and  carbonic  acid.  The  alcohol  may  reach 
2.5  per  cent,  but  koumiss  made  from  cow's  milk  may  not  contain 
above  i  per  cent.  Koumiss  becomes  stronger  in  both  taste  and  smell 
after  keeping  for  a  day  or  two.  It  is  highly  sensitive  to  temperature 
changes,  and  easily  putrefies. 

There  are  two  varieties  of  koumiss  prepared  which  differ  in  degree 
of  fermentation  and  in  their  exhilarating  and  intoxicating  properties. 
The  lighter  form  contains  less  alcohol  than  the  heavier,  in  which 
fermentation  has  proceeded  further. 

The  following  analysis  by  Stange  illustrates  the  changes  in  com- 
position which  koumiss  undergoes  by  prolonged  fermentation  : 


ANIMAL  FOODS. 


71 


Table  of  the  Relative  Composition  of  the  Several  Strengths  of  Koumiss. 

(Stange). 


Mare's 
milk. 

KOUMISS — DURATION 

OF   FERMENTATION. 

6  hours. 

18  hours. 

30  hours. 

4  days. 

Carbonic  acid 

51 
23 

5 

3.8 

6.0 

19-5 
5-6 
16.3 
22.6 
20.0 
4.0 

30.0 
6.4 

20.0 

19.0 

4.0 

II  .0 

Alcohol 

18 

3 

18 

22 

18 

4 

5 
9 

8 

5 
9 

5 

30.0 
6.4 

Lactic  acid 

Milk  sugar 

Albumin 

16.0 

Fat 

19.0 
4.0 

Salts 

The  casein,  after  being  first  precipitated,  is  converted  into  pep- 
tones and  an  acid  albumin.  It  should  be  remembered  that  the  com- 
position of  koumiss  is  always  changing  unless  the  fermentation  be 
constantly  held  in  check  by  extreme  cold.  Koumiss  grows  more  and 
more  acid  and  keeps  but  a  short  time  when  exposed  to  the  air.  If 
spoiled,  it  may  produce  severe  symptoms  of  ptomaine  poisoning. 

Koumiss  is  prepared  in  tablet  form  under  the  name  of  koumysgen, 
each  tablet,  it  is  claimed,  containing  30  per  cent  of  soluble  casein. 
The  tablets  keep  indefinitely  in  air-tight  bottles,  and  when  dissolved 
in  water  form  a  cooling  effervescing  food,  possessing  similar  proper- 
ties with  koumiss,  and  it  is  cheaper.  It  is  doubtful,  however,  whether 
any  preparation  can  be  made  to  reproduce  all  the  peculiarities  and 
advantages  of  fresh  koumiss,  which  is  so  variable  and  delicate  a 
substance. 

Koumiss  Cure.— The  "koumiss  cure  "  consists  in  giving  a  large 
quantity  of  koumiss — in  some  cases  15  to  20  tumblerfuls  a  day — in 
combination  with  nourishing  albuminous  food.  If  perfectly  fresh  it 
may  be  drunk  warm,  but  if  it  is  to  be  kept  for  some  time  it  is  better 
to  drink  it  cold.  Koumiss  which  is  either  too  fresh  or  which  has  not 
been  kept  clean  may  cause  flatulency,  colic,  and  diarrhoea,  but  old 
koumiss  has  the  opposite  effect  upon  the  bowels,  and,  like  milk,  gives 
rise  to  constipation.  Koumiss  resembles  whey  in  being  strongly  diu- 
retic and  diaphoretic,  and  thus  relieves  the  mucous  membranes  of 
congestion.  It  also  alleviates  thirst,  strengthens  the  action  of  the 
heart,  and  improves  the  vascular  tone,  general  nutrition,  and  com- 
plexion. The  solids  of  the  urine  are  increased  during  its  use.  The 
use  of  koumiss  is  said  to  be  contraindicated  in  renal  and  vascular 
diseases,  gout,  plethora,  and  chronic  constipation. 

At  first  but  two  or  three  tumblerfuls  of  koumiss  are  allowed  daily 
until  the  stomach  becomes  accustomed  to  it;  then  patients  are  made 
to  drink  a  glass  at  frequent  intervals  during  the  day  and  sometimes 
as  often  as  once  every  half  hour.  Some  patients  can  digest  very 
large  quantities  of  koumiss,  and  as  much  as  10  litres  have  been  taken 


72  FOODS  AND  FOOD  PREPARATIONS. 

in  twenty-four  hours,  but  less  is  used  now  than  formerly ;  patients 
do  not  often  exceed  6  or  8  litres  a  day,  and  for  the  average  from  2 
to  4  is  quite  enough.  Tender  beef  and  abundant  butter,  cream,  and 
a  moderate  supply  of  bread  compose  the  basis  of  the  other  foods 
allowed.  Sweets,  salads,  and  other  beverages  than  koumiss  are  for- 
bidden. 

The  treatment  should  be  commenced  slowly  in  order  to  accustom 
the  digestive  system  to  the  fermented  drink,  which  otherwise  may 
excite  diarrhoea.  The  latter  accident  may  be  counteracted  by  lime 
water  or  some  simple  remedy,  such  as  bismuth. 

The  koumiss  prepared  from  milk  in  the  United  States  does  not 
seem  to  possess  the  peculiar  properties  and  extraordinary  nutritive 
value  which  is  attributed  to  it  when  made  from  mare's  milk  in  Rus- 
sia, on  which  patients  are  said  to  gain  rapidly  in  weight.  In  various 
Russian  cities  there  are  special  institutions  designed  for  carrying  out 
the  koumiss  cure,  and  which  are  supplied  with  the  genuine  article 
from  the  steppes. 

Special  koumiss  cures  are  not  in  vogue  in  this  country,  but  in 
southeastern  Russia  there  are  several  establishments,  notably  in  the 
districts  of  Orenberg  and  Samara,  where  patients  go  for  treatment 
during  several  months  in  summer,  and  derive  great  improvement. 
Like  other  popular  "cure"  resorts  in  Europe,  these  establishments 
furnish  the  patient  with  suitable  light  and  varied  amusement  during 
the  progress  of  his  treatment,  which  is  highly  beneficial,  by  diverting 
the  mind  and  relieving  an  otherwise  monotonous  regime.  While  un- 
dergoing the  koumiss  cure,  patients  are  made  to  live  outdoors  as 
much  as  possible,  and  tent  life  with  free  exercise  is  no  doubt  a  very 
important  adjunct  to  the  treatment  when  it  can  be  obtained.  The 
climate  is  both  hot  and  dry,  and  the  elevation  is  high. 

The  koumiss  cure  is  particularly  available  for  chronic  catarrh  of 
the  respiratory  and  alimentary  canal,  and  in  the  first  stage  of  pul- 
monary tuberculosis.  It  is  also  especially  recommended  for  general 
debility  resulting  from  pronounced  anaemia,  and  for  various  diatheses, 
such  as  scrofula,  rhachitis,  etc.  The  large  percentage  of  carbonic 
acid  which  is  produced  by  koumiss  fermentation,  together  with  the 
alcohol  present,  acts  as  a  stimulant  to  the  gastric  mucous  membrane, 
favourably  affects  digestion,  and  lessens  irritability  of  the  stomach. 
Among  other  effects  produced  by  the  use  of  koumiss  may  be  men- 
tioned occasional  drowsiness  and  lassitude.  This  food  is  also  said 
to  possess  some  aphrodisiac  influence. 

Kefir. — Kefir  is  another  form  of  fermented  milk  which  resembles 
koumiss,  and  has  long  been  used  in  the  Caucasus. 

Kefir  contains  three  varieties  of  ferments  which  produce  complex 
fermentation  processes  resulting  in  the  formation  of  alcohol,  lactic 
acid,  modified  albumins,  and   peptones.     The  casein   of  milk   is  in 


ANIMAL  FOODS. 


73 


great  part  digested  by  them,  and  the  portion  which  remains  is  precip- 
itated in  flocculi  instead  of  heavy  curds.  The  milk  sugar  is  almost 
completely  converted  into  alcohol  and  carbonic-acid  gas,  which  bub- 
bles to  the  surface.  Kefir  has  a  sour  taste,  due  to  the  organic  acids 
which  it  contains. 

Matzoon. — Matzoon  is  a  form  of  milk  in  which  lactic-acid  fermen- 
tation has  been  produced  by  a  ferment  much  used  in  Syria.  It  has 
the  same  general  properties  and  effects  with  koumiss,  and  is  an  ex-. 
cellent  invalid  food. 

IV.  Methods  of  Sterilisation  and  Preservation. 

I.  Sterilisation.  2.  Pasteurisation.  3.  ''Humanised  milk."  4. 
Modified  milk.     Milk  laboratories. 

I.  Sterilised  Milk. — The  sterilisation  of  milk  is  accomplished  by 
heating  it  up  to  the  boiling  point,  212°  F.  In  a  vacuum  this  may  be 
accomplished  by  a  temperature  a  few  degrees  lower. 

The  construction  of  steam  sterilisers  for  milk,  beef  tea,  or  other 
foods  is  based  upon  a  very  simple  plan.  It  is  a  familiar  fact  that 
the  steam  which  rises  from  water  heated  in  a  tin  or  copper  can  con- 
denses in  drops  on  the  lid,  and  this  condensed  vapour  drips  back 
along  the  sides  of  the  can.  If  the  lid  is  raised  a  little  and  is  made 
somewhat  larger  than  the  can,  the  condensed  steam  will  drip  down 
on  the  outside  of  the  can  instead  of  the  inside.  If  a  second  larger 
can  be  inverted  like  a  hood  or  jacket  over  the  first,  the  steam  con- 
densed between  the  two  cans  drips  back  and  may  be  made  to  rejoin 
the  water  from  which  it  started.  In  this  way  a  kind  of  perpetual 
motion  is  kept  up  so  long  as  a  flame  is  applied  beneath  the  water  to 
vapourise  it.  Bottles  containing  the  food  to  be  sterilised  are  sus- 
pended in  racks  in  the  upper  part  of  the  inner  chamber  in  the  at- 
mosphere of  steam,  and  their  contents  soon  acquire  the  temperature 
of  boiling  water,-  212°  F. 

Siebert  removes  the  grosser  impurities  of  milk  by  placing  it  on  a 
thick  layer  of  sterilised  absorbent  cotton  in  a  clean  glass  funnel.  A 
quart  of  milk  will  pass  through  in  ten  or  fifteen  minutes. 

Mobrun  preserves  milk  for  six  months  by  warming  it  in  a  tin  re- 
ceptacle, the  only  opening  of  which  is  through  a  lead  tube.  The 
milk  is  rendered  sterile  by  the  heat,  and  all  air  is  driven  out  through 
the  tube,  which  is  then  compressed  and  soldered. 

The  taste  of  sterilised  milk  is  peculiar  and  resembles  that  of 
boiled  milk.  If  put  in  bottles  which  have  been  sterilised  by  boiling 
water  or  steam,  by  stopping  them  with  pledgets  of  absorbent  cotton 
which  have  been  baked,  the  milk  will  keep  fresh  for  a  number  of  days 
— long  enough  to  be  carried  upon  a  voyage  to  England  or  across  the 
continent.     This  milk  is  not  quite  so  easily  digested  as  boiled  milk. 

Milk  drawn  by  clean  hands  fresh  from  the  cow  into  bottles  which 


74 


FOODS  AND  FOOD  PREPARATIONS. 


have  been  sterilised  by  boiling  water  is  germ-free,  and  need  not  be 
further  treated  ;  but  the  milk  usually  served  in  cities  from  large  cans 
which  have  been  hawked  about  the  streets  has  passed  through  sev- 
eral receptacles  and  been  exposed  to  the  air  (see  Milk  Adultera- 
tion and  Impurities,  p.  51).  It  is  better  always  to  keep  milk  germ- 
free,  but  it  is  absolutely  necessary  to  do  so  in  summer  if  it  is  to  be 
fed  to  infants.  It  is  often  advisable  to  sterilise  it  for  feeding  to 
typhoid-fever  patients  and  others  in  whom  asepsis  of  the  alimentary 
canal  is  of  paramount  importance. 

If  milk  be  too  long  sterilised  it  becomes  of  a  brownish  hue,  owing 
to  the  conversion  of  its  lactose  into  caramel.  To  obviate  this,  it 
may  be  sterilised  on  two  or  three  successive  day.s,  for  a  few  min- 
utes only.  The  first  sterilisation  kills  the  germs,  but  not  necessarily 
their  spores,  which  are  destroyed  by  the  second. 

It  is  suggested  by  Barlow  that  prolonged  sterilisation  of  milk 
may  lessen  its  antiscorbutic  powers  for  young  infants,  but  scurvy  in 
infants  is  due  to  other  causes,  such  as  feeding  with  artificial  foods, 
and  prolonged  exclusive  milk  diet  for  adults  reduces  them  to  a  con- 
dition resembling  scurvy  (see  Typhoid  Fever,  Milk  Diet,  page  398). 

According  to  Leeds,  the  following  alterations  are  produced  in 
milk  by  sterilisation  at  212°  F. : 

1.  The  amylolytic  ferment  is  destroyed. 

2.  The  casein  coagulates  less  readily  by  rennin. 

3.  The  digestibility  of  casein  by  the  gastric  and  pancreatic  juices 
is  somewhat  retarded. 

4.  The  fat  is  not  so  promptly  absorbed. 

5.  If  the  heating  is  continued  for  some  time,  the  milk  sugar  is  de- 
stroyed. 

In  churning  sterilised  milk,  butter  forms  more  slowly  than  from 
raw  milk,  a  period  two  or  three  times  longer  being  required.  Hirsch 
attributes  this  to  toughening  of  the  albuminoid  envelopes  (of  lactal- 
bumin)  of  the  fat  globules,  which  is  produced  by  the  heat. 

For  these  several  reasons  an  infant  to  be  fully  nourished  on  ster- 
ilised milk  requires  more  of  it  than  of  raw  milk. 

Practically,  in  normal  stomachs  of  either  infants  or  adults  these 
changes  are  not  sufficiently  pronounced  to  seriously  interfere  with 
the  digestibility  of  the  milk,  but  dyspeptic  and  catarrhal  conditions 
of  the  stomach,  especially  in  infants,  make  it  highly  sensitive  to  very 
slight  modifications  in  the  composition  and  reaction  of  milk.  In 
quite  recent  years  it  has  been  proved  that  the  method  of  Pasteurisa- 
tion is  preferable  to  sterilisation,  and  it  is  now  much  more  in  vogue 
except  where  milk  has  to  be  prepared  to  keep  for  several  days  (see 
2.  Pasteurised  Milk,  p.  75). 

The  directions  for  predigestion  combined  with  sterilisation  of 
milk  at  the  Philadelphia  Hospital  are  thus  given  by  Hirst: 


ANIMAL  FOODS. 


75 


"  I.  Have  the  nursing  bottles  prepared  clean  every  morning. 

"  2.  Take  cream,  five  ounces;  milk,  two  and  a  half  ounces. 

"  3.  Put  in  skillet ;  add  pancreatin  powder  (pancreatin,  two  and  a 
half  grains ;  sodium  bicarbonate,  five  grains) ;  heat  over  alcohol  flame 
for  six  minutes  ;  stir  and  sip  constantly  ;  do  not  overheat. 

"4.  Of  this  mixture  put  in  each  bottle  six  drachms  (for  a  two- 
ounce  bottle).     Use  funnel. 

"  5.  Add  to  each  bottle  ten  drachms  of  sugar  solution.  (Make 
sugar  solution  by  dissolving  an  ounce  of  sugar  of  milk  (one  powder) 
in  a  pint  of  warm  water.) 

"  6.  Stopper  the  mouth  of  each  bottle  with  dry  baked  cotton  and 
sterilise  for  twenty  minutes. 

"  7.  Set  aside  to  cool. 

"8.  Before  use,  put  bottle  in  warming  cup;  apply  nipple  imme- 
diately before  giving  it  to  infant." 

The  alimentary  canal  of  the  newborn  infant  is  sterile — it  con- 
tains no  bacteria — but  after  the  first  few  passages  of  meconium  two 
species  of  bacilli  and  one  of  micrococci  are  found  (Escherich,  Bes- 
lau),  which  disappear  with  the  meconium.  There  are  but  two  species 
of  bacteria  found  in  the  stools  of  healthy  nursing  infants,  the  Bacr 
terium  lactis  arogenes,  obtained  from  the  ileum  below  the  duodenum, 
and  Bacterium  coli  commune,  from  the  colon. 

In  diarrhoeal  conditions  other  bacteria,  to  the  number  of  forty 
species,  have  been  found  (Booker).  Their  action  in  different  dis- 
eases is  not  yet  differentiated,  but  they  are  associated  more  or  less 
directly  with  malfermentation  and  the  formation  within  the  intes- 
tines of  gases  and  irritable  or  poisonous  products.  Many  of  these 
species  thrive  and  are  reproduced  in  hot  weather  outside  the  body 
in  milk,  in  the  atmosphere,  and  upon  diapers  and  utensils.  This 
explains  the  importance  of  absolute  antiseptic  cleanliness  in  every- 
thing that  pertains  to  the  nursing  and  feeding  of  infants — cleanliness 
of  the  breasts  and  nipples,  of  the  nurse's  hands,  of  all  receptacles  for 
milk  or  other  foods,  of  the  child's  body,  and  prompt  removal  and 
disinfection  of  soiled  diapers  or  clothing. 

Most  of  these  bacteria  grow  best  in  milk,  and  the  diarrhoeal  dis- 
eases which  are  caused  by  and  associated  with  them  are  absolutely 
preventable  when  the  methods  are  understood  of  avoiding  milk  in- 
fection, and  of  sterilisation  when  it  is  infected.  Vaughan  says  with 
proper  emphasis:  "  If  parents  were  willing  to  pay  for  wholesome  un- 
infected milk  half  the  fancy  price  which  they  readily  give  for  some 
prepared  baby  food,  their  children  would  be  better  nourished  and  dis- 
ease among  them  would  be  less  frequent." 

2.  Pasteurised  Milk. — Pasteurised  milk  is  similarly  prepared 
to  sterilised  milk,  and  is,  in  fact,  sterile,  but  the  temperature  is  only 
raised  for  ten  to  twenty  minutes  to  160°  tp  1 70°  F.,  instead  of  the  boil- 


76  FOODS  AND  FOOD  PREPARATIONS. 

ing  point,  212°  F.  It  is  somewiiat  more  easily  digested  than  sterilised 
milk,  but  it  does  not  keep  so  long  and  spoils  in  one  or  two  days.  It 
has  the  advantage  of  tasting  more  like  fresh  milk. 

Cleansing  Milk  Bottles. — Both  sterilised  and  Pasteurised  milk  should 
be  warmed  by  placing  the  milk  bottles  in  warm  water  without  open- 
ing them.  If  the  bottles  are  to  be  used  again  they  should  be  rinsed 
and  left  standing  full  of  water  to  which  one  or  two  teaspoonfuls  of 
borax  or  soda  have  been  added.  Before  filling  with  milk  they  should 
be  washed  with  a  fresh  swab  and  hot  soapsuds,  rinsed  again  with 
boiled  water,  and  kept  for  at  least  twenty  minutes  in  boiling  water, 
or  they  may  be  placed  in  a  steam  sterilising  apparatus  under  pres- 
sure. Rubber  nipples  for  infants'  bottles  must  be  kept  in  borax 
water  and  rinsed  several  times  daily. 

The  heat  of  Pasteurisation  is  sufficient  to  destroy  all  bacteria 
likely  to  be  present  without  so  much  alteration  of  the  properties  of 
the  milk  as  occurs  in  sterilisation. 

Different  experimenters  have  shown  that  the  tubercle  bacillus  in 
milk  is  destroyed  by  a  ten-minutes  exposure  at  167°  F.,  whereas  the 
germs  of  cholera,  pneumonia,  and  typhoid  fever  may  be  quickly  de- 
stroyed in  milk  at  140°  F.  (Van  Geuns). 

Freeman  has  shown  by  experiments  that — 

"  I.  Pasteurisation  of  milk  at  about  75°  C.  affords  a  safeguard 
against  the  deleterious  effects  of  any  bacteria  which  it  may  contain, 
without  interfering  with  its  nutritive  qualities. 

"Pasteurisation  at  about  75°  C.  (167°  F.)  destroys  efficiently  the 
germs  of  cholera,  typhoid  fever,  diphtheria,  and  tuberculosis  as  well 
as  the  Streptococcus  pyogenes,  the  Staphylococcus  pyogenes  aureus,  and  the 
Bacillus  coli  commutiis." 

The  Bacillus  acidi  lactici  is  also  prevented  from  acting  after  ex- 
posure to  a  temperature  of  160°  F. 

To  be  wholly  innocuous  milk  should,  therefore,  be  heated  above 
160°  F.,  but  not  over  167°  F.  It  is  found  that  by  immersing  bottles 
of  milk  in  water  which  has  just  been  removed,  while  boiling,  from 
the  fire,  a  fairly  uniform  temperature  of  167°  F.  is  obtained.  Natu- 
rally, the  relation  between  the  volume  of  water  used  and  the  quantity 
of  milk  must  be  properly  balanced,  and  various  forms  of  graduated 
receptacles  are  sold  which  make  the  process  very  easy  and  simple. 

A  graduated  covered  pail,  into  which  the  boiling  water  is  poured, 
is'fitted  with  a  rack  to  submerge  enough  bottles  of  milk  for  the  day's 
use,  and  this  is  all  that  is  necessary.  After  half  an  hour's  exposure 
to  the  heat  the  milk,  as  in  the  case  of  sterilised  or  pancreatinised 
milk,  is  set  in  a  refrigerator  until  ready  for  use. 

Under  some  conditions  both  sterilised  and  Pasteurised  milk  form 
smaller  curds  than  raw  milk,  although  this  is  not  the  case  with  the 
coagulae  formed  by  gastric  juice  (Freeman). 


ANIMAL   FOODS. 


71 


The  poor  in  New  York  city  are  now  supplied  with  cheap  Pasteur- 
ised milk  through  the  philanthropy  of  Mr,  Nathan  Strauss,  who  in 
1893  opened  the  first  milk  depot  for  dispensing  pure  milk  and  Pas- 
teurised milk,  at  a  cost  of  but  one  and  a  half  cent  for  an  eight- 
ounce  bottle.  A  sterilised  nipple  is  also  furnished  with  each  bottle. 
The  bottles  have  sloping  necks,  to  facilitate  cleansing,  and  spheroidal 
bottoms  to  prevent  them  from  being  left  standing  about  uncorked. 
In  an  account  of  this  system  by  Dr.  Freeman,  in  the  New  York  Medi- 
cal Record  (August  4,  1894),  he  says  : 

"  In  addition  to  Pasteurised  ordinary  milk  and  Pasteurised  modi- 
fied milk  as  supplied  last  year,  a  Pasteurised  milk  diluted  with 
barley  water  and  sweetened  with  cane  sugar,  and  containing  also 
table  salt,  has  been  introduced  at  the  suggestion  of  Dr.  Jacobi. 
The  formula  used  is : 

Table  salt i  oz. 

White  cane  sugar 10  " 

Milk I  gal. 

Water i    " 

"  This  barley  milk  will  be  dispensed  in  six-ounce  bottles." 
3.  Humanised  Milk. — Humanised    milk  is   really  Pasteurised 
milk   but  with  a  permanent  alkaline  reaction  and  partial  prediges- 
tion.     Leeds  claims  the  credit  for  the  origin  of  the  idea  of  this  form 
of  milk,  and  his  formula  is : 

Milk \  pint. 

Water \     " 

Cream 4  tablespoonfuls. 

Peptogenic  milk  powder i  large  measure. 

Heat  to  160°  to  170°  F.  for  ten  to  twenty  minutes. 

Instead  of  cream,  some  other  form  of  fat  may  be  added  for  inva- 
lids, such  as  olive  or  cod-liver  oil  or  cacao  butter. 

The  name  "humanised  milk"  is  applied  somewhat  indefinitely 
to  various  preparations  of  cow's  milk  in  which  the  attempt  is  made 
to  approach  more  nearly  the  composition  of  human  milk  by  lessen- 
ing the  casein  and  increasing  the  sugar  and  fat.  These  prepara- 
tions are  partially  predigested,  but  the  pancreatinisation  is  stopped 
before  it  has  proceeded  far,  so  that  the  infant  stomach  shall  still 
have  some  work  to  do. 

Another  good  mixture  designed  to  resemble  human  milk  is  that 
of  Meigs : 

Cream 2  tablespoonfuls. 

Milk I  tablespoonful. 

Lime  water i  " 

Water 3  tablespoonfuls. 

Milk  sugar \  teaspoonful. 


78 


FOODS  AND   FOOD  PREPARATIONS. 


4.  Modified  Milk.  Milk  Laboratories. — The  establishment 
of  milk  laboratories  having  in  view  the  object  of  modifying  cow's 
milk  for  infant  and  invalid  feeding  has  demonstrated  the  practical 
value  of  this  work.  Such  milk  is  now  called  "  modified  milk."  The 
laboratory  which  was  founded  in  Boston  during  i892-'93,  upon  the 
suggestions  of  Dr.  Rotch,  completely  fed  about  twelve  hundred 
infants  and  was  patronised  by  more  than  one  hundred  and  fifty 
physicians  in  its  first  year.  A  similar  laboratory  was  recently 
opened  in  New  York.  The  milk  is  derived  from  carefully  selected 
animals  kept  at  farms  where  their  food,  stabling,  drinking  water, 
and  pasture  are  under  the  scientific  supervision  of  a  veterinary 
surgeon. 

It  is  now  generally  acceded  that  infants  thrive  better  in  the  long 
run  upon  mixed  milk  derived  from  several  cows  than  by  the  exclusive 
use  of  milk  from  a  single  animal,  which  is  more  apt  to  vary  with  the 
condition  of  the  cow  at  different  times,  but  it  is  possible  to  avoid 
all  variation  in  milk  and  keep  it  at  an  absolutely  uniform  standard 
or  at  a  standard  which  can  be  graded  to  correspond  with  the  in- 
creasing age  of  the  infant,  by  the  employment  of  proper  means 
in  the  milk  laboratories,  where  milk  can  be  prepared  with  its  in- 
gredients mixed  with  the  accuracy  of  a  medicinal  prescription, 
while  its  freshness  and  sterility  are  absolutely  ensured.  If  desired 
also,  the  milk  may  be  predigested  in  the  laboratory,  and  sweet 
whey  and  other  materials  derived  from  fresh  milk  may  be  obtained 
there. 

Physicians  are  furnished  with  blank  forms  upon  which  they  can 
definitely  prescribe  the  composition  of  the  milk  which  they  wish  to 
order  for  any  individual  case.  A  sample  prescription  form  is  here- 
with appended : 


Per  cent. 

Remarks. 

Fat 

Number  of 

Milk  sugar 

feedings  ? 

Albuminoids 

Mineral  matter 

Amount  at 

each  feeding? 

Total  solids 

Water 

Infant's  age  ? 

lOO.OO 

Infant's  weight  ? 

For  whom  ordered. 


Date.  Signature. 


PLATE  I. 


Centrifugal 
Separator. 


Sterilizer. 
Capacity  500  pints. 


Care  of  Modifying  Materials.         Aseptic  Precautions. 


Milk  Room  and  Coolers  for 
modifying  materials. 


Special  Sterilizers  for 
returned  packages. 


MILK    LABORATORY  (INTERIOR). 
(From  Paediatrics,  by  T.  M.  Rotch,  M.  D.) 


ANIMAL   FOODS. 


79 


"If  the. physician  does  not  care  to  mention  the  especial  per- 
centage, he  can  ask  for  percentages  which  will  correspond  to  the 
analysis  of  human  milk,  and  he  can  then  vary  any  or  all  of  these 
percentages  later,  according  to  the  need  of  the  especial  infant  pre- 
scribed for"  (Rotch). 

In  order  to  prepare  modified  milk  by  Rotch's  method  it  is  neces- 
sary to  have:  i.  Pure  cream  containing  the  fat.  2.  Pure  milk  con- 
taining the  albuminoids  and  no  fat.  3.  Distilled  water.  4.  A  "20-per- 
cent solution  of  milk  sugar  made  fresh  daily  with  distilled  water.  5. 
Lime  water. 

The  milk  and  cream  are  separated  completely  by  an  apparatus 
made  to  revolve  6,800  times  per  minute,  so  that  they  may  be  recom- 
bined  in  any  desired  proportion.  The  resulting  cream  has  an  almost 
stable  quantity  of  fat,  16  per  cent  (Rotch).  After  separation  of  the 
cream  the  milk  is  modified  according  to  the  formula  prescribed  for 
each  case,  and  sterilised  or  Pasteurised. 

Rotch  gives  the  following  sample  prescriptions  for  modified  milk 
to  be  sent  by  the  physician  to  the  laboratory.  As  the  use  of  modi- 
fied milk  is  a  new  method  of  treatment,  they  will  prove  instructive, 
and  are  therefore  given  in  full : 

5  ( I )  A  girl  6  years  old :  duodenal  jaundice. 

Fat 0.50 

Milk  sugar 6.00 

Albuminoids 4.00 

Give  4  ounces  every  two  hours. 
Send  12  tubes,  each  4  ounces  ;  lime  water,  t[V- 
Note. — This  case  made  a  rapid  recovery.     No  medicines  were  given. 

Q  (2)  A  boy  6  weeks  old  :  healthy. 

Fat 3.00 

Milk  sugar 7.00 

Albuminoids 1 .  50 

Send  12  tubes,  each  2  ounces. 
Lime  water,  ^<s- 
Sterilise  at  167°. 

Q  (3)  A  boy  6  months  old  :  healthy. 

Fat 4.00 

Milk  sugar 7.00 

Albuminoids 2 .  CX3 

Send  8  tubes,  each  6  ounces. 

Lime  water,  ^. 

Sterilise  at  167". 
9  (4)  A  girl  4  months  old  :  albuminoid  digestion  weak. 

Fat 4.00 

Milk  sugar 7 .  00 

Albuminoids o.  75 

Send  8  tubes,  each  4  ounces. 

Lime  water,  ^g. 

Sterilise  at  167°. 
8 


80  FOODS  AND  FOOD  PREPARATIONS. 

9  (5)  A  boy  6  months  old  :  sugar  digestion  weak. 

Fat '. .  3-00 

Milk  sugar 4.00 

Albuminoids 2.00 

Send  8  lubes,  each  6  ounces. 

Lime  water,  vV- 

Sterilise  at  167°. 

9  (6)  A  girl  4  months  old  :  summer  diarrhoea.     Food  has  to  be  sent  out  of  town 
by  express. 

Fat 2.00 

Milk  sugar 5.00 

Albuminoids.. i  .00 

Send  20  tubes,  each  i  ounce  and  i  drachm. 

At  time  of  each  feeding  add  lime  water,  3  drachms. 

Sterilise  at  212°. 

Note. — In  this  case  the  diarrhoea  had  not  been  sufficiently  studied  to  determine 
whether  it  was  putrefactive  or  fermentative,  so  that  a  safe  general  prescription  was 
sent  to  begin  with.  The  lime  water  had  to  be  introduced  at  each  feeding  on  account 
of  the  212°  sterilisation,  necessitated  by  the  hot  weather  and  the  distance  to  be  sent. 

According  to  Rotch,  "certain  breeds  of  cows  are  better  than 
others  for  copying  human  milks." 

List  of  Breeds  best  Adapted  for  Modified  Milk,  with  Analyses  (Rotch). 


Durham 

Devon 

Ayrshire 

Holstein-Friesian . 
American  grades . , 
Common  natives .  . 


Fat. 

Milk 

Albumi- 

Mineral 

sugar. 

noids. 

matter. 

Per  cent. 

Per  cent. 

Per  ceat. 

Per  cent. 

4.04 

4-34 

4.17 

0.73 

4.09 

4-32 

4.04 

0.76 

3-89 

4.41 

4.01 

0.73 

2.88 

4-33 

3-99 

0.74 

4.01 

4-36 

4.06 

0.74 

3-69 

4-35 

4.09 

0.73 

Total  solids. 


Per  cent. 
13-28 
13.21 
13.04 
11.94 

13-17 
12.86 


Water. 


Per  cent. 
86.72 
86.79 
86.96 
88.06 
86.83 
87.14 


Many  so-called  "  milk  foods "  are  sold  for  infant  and  invalid 
use.  Their  object  is  to  furnish  a  ready-made  substitute  for  fresh 
milk,  which  is  easy  of  preparation  even  by  an  unintelligent  nurse. 
Generally  speaking,  the  continued  use  of  such  foods,  especially  for 
young  growing  infants,  is  to  be  condemned  whenever  fresh  milk  is 
obtainable,  but  in  travelling  at  sea,  or  wherever  good  milk  is  not 
procurable,  and  in  other  emergencies,  they  may  be  resorted  to  with 
advantage,  until  more  favourable  conditions  obtain.  Analyses  of 
some  of  the  best  known  of  these  foods  are  appended  below,  and 
compared  with  the  composition  of  mother's  milk. 


ANIMAL   FOODS. 


Name  of  Food. 


Ideal  mother's  milk. 

Malted  milk 

Nestle's  milk  food.. 
Carnrick's  soluble  . 
Lacto  preparata  . . . 

Lactated  food 

Malted  milk 

Nestle's  milk  food . 
Carnrick's  soluble. . 

Lactated  food 

Carnrick's  soluble  . 
Lactated  food 


Analysed 
by. 


Rach. 


Leeds. 


Stutzer. 


Wa- 
ter. 


4.00 

3-27 
4-51 
5-93 
5.80 
7.80 
2.18 


Sugar. 


Dex- 
trin. 


Starch. 


46.78: I... 

46.63  17.16  . .  , 

37-47j  4-84  33. 
30.12    9.14  38. 

63-381 1... 

28.66:10.33  35. 
50.4016.09     5. 

38.95 
27.08 
29.65 
28.11 
25-52 


40 

i37 

9-35,36 

41 

152 


Albu- 

Fat. 

mi- 
noids. 

Ash. 

23-39 

23 -.39 

2-44 

6.78 

22.26 

390 

5-37 

13.00 

1-59 

2.96 

10-75 

3.02 

12.35 

14-51 

3.66 

1.82 

13.48 

2.77 

3-30 

lb. 88 

3-1:3 

1. 91 

8.23 

I -59 

7-45 

10.25 

4-42 

1.64 

11-85 

2.61 

5-53 

16.69 

3.00 

2.19 

9-05 

2.26 

Solubility  in 
water. 


Very  soluble. 
Insoluble. 


Lacto  preparata  is  a  preparation  of  pure  selected  milk  from 
which  the  cream  has  been  removed  by  centrifugal  force,  and  for 
it  is  substituted  cacao  butter,  which  keeps  better  and  is  quite 
nutritious.  Lime  water  is  then  added  and  the  mixture  is  sterilised, 
evaporated,  powdered,  and  sealed  hermetically  in  cans. 

The  other  foods  of  the  list  above  given  all  contain  considerable 
starch,  and  will  therefore  be  described  in  the  section  upon  Pre- 
pared Farinaceous  Foods  (see  page  130). 

Milk  Derivatives. 

The  principal  foods  derived  from  milk  which  are  in  common  use 
are : 

I.  Condensed  milk.  2.  Cream.  3.  Butter.  4.  Buttermilk.  5. 
Cheese.     6.  Whey. 

I.  Condensed  Milk. — Condensed  milk  is  prepared  by  slowly 
evaporating  the  water  of  milk  by  moderate  heat  in  vacuo  to  the  con- 
sistence of  honey.  There  are  two  varieties:  the  "plain,"  which  is 
condensed  to  about  one-fourth  of  its  bulk  and  superheated,  and  to 
which  little  or  no  sugar  is  added ;  a  stronger,  more  condensed  sort, 
with  which  cane  sugar  is  mixed  in  excess.  Such  milk  yields  from 
39  to  48  per  cent  of  sugar  among  its  solid  ingredients,  but  some- 
times as  much  as  75  per  cent  is  added.  A  good  deal  of  the  Swiss 
condensed  milk  sold  in  market,  as  well  as  that  made  in  this  country, 
contains  40  per  cent  of  sugar. 

The  sugar  prevents  fermentation  and  decomposition,  and  when 
condensed  milk  is  put  up  while  hot  in  hermetically  sealed  tin  cans  it 
will  keep  fresh  for  years.  It  will  even  remain  fresh  for  several  days 
after  a  can  is  opened.  It  is  soluble  in  water  added  to  any  degree  of 
dilution.  Condensed  milk  is  largely  used  for  the  nourishment  of 
infants,  especially  among  the  poorer  classes.  They  thrive  upon  it 
for  a  time,  occasionally  even  better  than  on  raw  milk,  and  it  makes 
them  fat,  owing  to  the  extra  sugar  which  it  contains.     It  does  not 


82  FOODS  AND  FOOD  PREPARATIONS. 

constipate,  and  may  be  even  slightly  laxative.  But  although  such 
babies  may  appear  robust,  their  flesh  is  less  firm  and  they  develop 
poorly,  are  less  able  to  resist  disease,  and  become  rachitic. 

Condensed  milk  should  be  diluted  ten  times  for  a  child  a  month 
or  two  old,  and  cream  should  be  added  in  liberal  proportion. 

The  formula  recommended  by  Starr  is : 

Condensed  milk 3  j  ; 

Cream f  5  ss. ; 

Hot  water f  §  ijss. 

This  milk,  when  diluted,  speedily  undergoes  lactic,  acid  fermen- 
tation and  causes  diarrhoea  and  thrush. 

Condensed  milk  has  been  used  with  advantage  in  the  treatment 
of  dysentery  (Hiibner)  and  as  a  prophylactic  against  scurvy.  It  is 
serviceable  on  long  voyages  and  expeditions  where  fresh  milk  can- 
not be  obtained  for  use  with  tea,  coffee,  etc. 

Unsweetened  condensed  milk  made  of  fresh  Swiss  Alpine  milk, 
and  sold  under  various  brands  in  this  country,  is  prepared  by  evapo- 
ration by  heat  sufficiently  strong  to  render  the  milk  aseptic,  so  that 
no  preservative  materials  are  added.  The  water  is  reduced  from 
the  normal  standard  of  88  per  cent  to  about  6i  per  cent.  It  is  open 
to  the  same  objections  as  the  use  of  sterilised  milk  (see  Sterilised 
Milk,  p.  73)  but  it  is  better  for  infants  than  those  forms  of  condensed 
milk  in  which  preservation  is  secured  by  the  addition  of  too  large  a 
proportion  of  cane  sugar.  An  analysis  of  one  brand  of  this  milk 
is  given  by  Prof.  Goodfellow,  as  follows : 

Water 61.3 

Casein 9.1 

Albumin 1.5 

Fat II. 7 

Lactose 14-3 

Salts  (mineral  matter) 2.1 

100. o 

Milk  may  be  preserved  for  some  time  in  hermetically  sealed  cans 
or  bottles  without  previous  condensation,  but  a  separation  of  the 
cream  eventually  takes  place,  and  butter  forms  m  the  can. 

2.  Cream. — Cream  is  the  fat  of  milk,  which,  by  virtue  of  its 
light  specific  gravity,  floats  to  the  top  of  vessels  in  which  milk  is 
allowed  to  stand  for  some  hours.  The  globules  collect  in  a  yellow 
layer  of  varying  thickness.  The  rise  of  the  cream  is  retarded  by 
coagulation,  but  favoured  by  a  cool  temperature  and  by  richness  of 
the  milk.  Cream  is  best  obtained  by  placing  the  milk  in  broad,  shal- 
low pans.  The  fatty  material  is  complex,  and  consists  of  glycerides 
of  stearic,  palmitic,  myristic,  oleic,  butyric,  and  soluble  fatty  acids. 
Churning  the  milk  causes  the  globules  of  fat  to  coalesce  in  small 
lumps  and  form  butter.     It  is  a  popular  fallacy  that  a  little  warm 


ANIMAL   FOODS. 


83 


water  added  to  milk  increases  the  cream  formation.  It  lessens  the 
specific  gravity  of  the  milk  and  hastens  the  floating  of  the  globules, 
but  the  ultimate  quantity  of  cream  is  not  affected.  If  the  cream 
falls  below  5  per  cent  of  the  volume  of  milk,  the  milk  has  been 
watered.  The  normal  average  quantity  of  cream  is  over  8  or  9 
per  cent,  but  there  may  be  above  20  per  cent.  The  breed,  age,  and 
feed  of  the  cow  have  a  marked  influence  upon  the  quantity  of  cream. 
The  Alderney  milk  is  rich  in  fat.     Longhorns  give  more  casein. 

The  milk  which  comes  from  the  cow  towards  the  end  of  milking 
contains  more  cream  than  that  which  is  first  drawn.  This  is  said  to 
be  due  to  the  rising  of  the  fat  in  the  "bag."  This  fact  should  be 
borne  in  mind  by  those  who  use  milk  drawn  direct  from  the  cow 
into  separate  small  vessels.  Afternoon  milk  is  richer  than  morning 
milk  in  both  proteid  and  fat. 

Centrifugal  Cream. — An  ingenious  process  has  recently  been  em- 
ployed for  rapidly  obtaining  milk  by  centrifugal  force.  A  small  and 
large  drum  are  placed  one  within  the  other,  leaving  a  space  of  a  few 
inches  between.  The  inner  drum  is  made  of  porous  material.  It  is 
filled  with  milk  and  set  in  rapid  revolution.  The  lighter  cream  re- 
mains in  the  inner  drum,  while  the  other  ingredients  are  thrown  with 
such  violence  against  the  porous  wall  that  they  are  forced  through 
it  into  the  outer  drum.  It  is  claimed  that  the  cream  is  more 
thoroughly  separated  in  this  manner  than  when  it  is  allowed  to  rise 
on  standing,  and  the  process  is  far  more  rapid. 

Condensed  or  evaporated  cream,  which  is  now  offered  in  market, 
consists  of  about  one  fourth  cream  and  three  fourths  other  ingre- 
dients of  milk,  the  whole  milk  having  been  evaporated  by  machinery. 
It  is  therefore  a  natural  product,  easily  digestible  on  account  of  the 
dilution  of  the  cream  with  the  nitrogenous  ingredients  of  the  milk, 
and,  unlike  much  condensed  milk,  it  is  not  artificially  sweetened.  It 
is  sometimes  mixed  with  malt  extract. 

Clotted  or  Devonshire  cream  is  skimmed  from  heated  milk,  so  that 
the  albumin  is  coagulated  with  it.  It  is  warmed  over  a  slow  fire  not 
above  150°  F.  Fothergiil  wrote,  "  Devonshire  cream  is  delicious 
with  preserved  ginger,  while  cream  and  maraschino  form  a  nutritive 
drink  for  the  affluent  consumptive." 

In  cooking,  suet  is  sometimes  added  to  replace  cream  and  impart 
additional  colour  and  flavour  to  milk. 

Cream  is  one  of  the  most  wholesome  and  agreeable  forms  of  fat. 
It  is  often  eaten  too  rich,  and  may  disagree  on  that  account,  whereas, 
diluted  with  an  equal  bulk  of  water  or  of  lime  water,  it  is  well  borne. 
It  is  an  excellent  substitute  for  cod-liver  oil  in  tuberculosis,  for,  al- 
though not  quite  so  digestible,  most  persons  prefer  to  take  it.  It  is 
an  excellent  food  for  cases  of  scrofulous  diathesis  and  long-continued 
suppurative  diseases,  such  as  empyema  or  tubercular  joint  diseases. 


34  FOODS   AND   FOOD   PREPARATIONS. 

It  should  be  avoided  in  flatulent  dyspepsia,  in  most  forms  of  gastric 
disease,  obesity,  ar.d  gallstones. 

It  is  useful  as  a  substitute  for  milk  when  digestive  disorders, 
diarrhcEa,  marasmus,  etc.,  occur  in  infants.  It  should  be  considerably 
diluted  when  so  given. 

The  addition  of  liquors  to  cream  lessens  its  digestibility  just  as 
heat  does,  for  alcohol  coagulates  and  toughens  the  proteid  envelopes^ 
of  the  fat  globules. 

Ice  cream,  when  very  simply  made,  is  nutritious,  and  may  be 
allowed  to  many  patients.  It  is  soothing  to  inflamed  throats  and 
enjoyed  by  convalescents  from  fevers,  and  children  who  object  to 
milk  will  often  take  it.  It  should  be  eaten  very  slowly,  so  that  it 
may  become  well  warmed  in  its  passage  to  the  stomach ;  otherwise  it 
retards  digestion. 

3.  Butter. — Butter  is  made  from  cream  by  the  mechanical  rup- 
ture of  the  albuminous  envelopes  which  enclose  the  fat  globules. 
The  globules  then  adhere  together  into  small  masses.  The  rupture 
is  accomplished  by  churning,  and  after  the  butter  is  of  sufficient 
density,  salt  in  small  proportion  is  added,  and  the  butter  is  "  worked  " 
over  with  a  spatula  and  frequently  washed. 

An  average  sample  of  good  butter  contains :  Water,  5  to  10  per 
cent ;  fat,  1 1.7  per  cent ;  casein,  0.5  per  cent ;  milk  sugar,  0.5  per  cent 
(Konig).  The  fats  comprise  six  neutral  varieties,  four  of  which, 
being  volatile,  give  to  it  taste  and  odour  (Chevreu). 

The  quantity  of  casein  in  butter  can  be  roughly  estimated  by 
melting  a  specimen  in  a  test  tube.  The  casein  forms  a  layer  at  the 
bottom,  which  in  a  good  sample,  according  to  Parkes,  should  not 
exceed  one  third  of  the  whole. 

Butter  should  not  have  less  than  0.5  to  2  per  cent  nor  more 
than  8  per  cent  of  salt  added. 

Perfectly  fresh  butter  made  without  salt  is  comparatively  taste- 
less and  keeps  poorly.  The  decomposition  of  its  nitrogenous  ma- 
terial liberates  a  ferment  which  separates  fatty  acids  and  glycerin. 

Butter  is  adulterated  by  dealers  by  beating  it  up  with  water  and 
by  adding  other  fats,  especially  suet  and  oleomargarine.  The  sophis- 
tication with  water  is  easily  detected  by  melting,  when  the  sample 
separates  into  two  layers. 

Fresh  butter  if  kept  too  long,  especially  in  hot  weather,  soon 
becomes  rancid,  bitter,  and  unwholesome. 

Butter  which  contains  too  much  water  and  too  many  ingredients 
other  than  the  fat  has  not  been  sufficiently  "  worked,"  and  is  also 
liable  to  become  rancid  and  cause  violent  gastric  derangement. 
Very  thorough  washing  of  butter  when  first  made  will  remove  much 
of  its  proteid  substance  and  tend  to  prevent  its  fermentation ;  and 
fresh  butter  which  has  once  become  rancid  may  be  rendered  less  so 


PLATE  II. 


Butter  x  40. 


BUTTERINE  X   40. 
ANIMAL    FAT8,    MAGNIFIED. 


[From  Bulletin  No.  IS,  LHvi»ion  of  Chemistry,  United  Sttiten  Agriculturtd  Bureau). 


iroTO    HY  (  I.IKI(illl>  KICHARDHON. 


ANIMAL   FOODS. 


85 


by  melting  and  shaking  it  in  boiling  water  which  is  several  times  re- 
newed and  then  pouring  it  into  ice-cold  water.  It  is  then  called 
"smalt."  The  addition  of  salt  to  butter  in  the  strength  of  twenty  to 
twenty-five  grammes  per  kilogramme  postpones  or  prevents  the  fer- 
mentation, and  sugars  or  syrups  in  which  the  butter  mjiy  be  immersed 
have  the  same  effect.  So  also  does  protecting  it  from  atmospheric 
air  in  hermetically  sealed  jars  set  in  cold  water,  or  simply  keeping 
it  under  fresh  water  which  is  renewed  two  or  three  times  a  day. 
Sometimes  weak  solutions  of  tartaric  or  acetic  acid,  three  grammes 
to  the  litre  (Hayem),  are  employed  for  this  purpose. 

Pure  fresh-butter  fat  is  not  crystalline,  but  old  or  rancid  butter 
becomes  so. 

An  ingenious  process  for  making  rancid  butter  sweet  again  has 
been  employed  in  California.  The  butter  is  melted  in  a  tub  in  which 
the  electrodes  of  an  electric  battery,  encased  in  flannel,  are  placed 
so  that  a  current  of  electricity,  when  passed  through  the  butter  from 
one  pole  to  the  other,  determines  a  collection  of  the  acids  causing 
the  rancidity  at  one  or  the  other  pole.  In  striving  to  reach  the 
pole  the  acids  soak  into  the  flannel,  and  may  be  then  removed. 

Strong-tasting  butter  is  not  necessarily  unwholesome,  for  the 
flavour  may  have  been  derived  from  the  cow  having  fed  upon  dead 
leaves  or  turnips,  and  butter  is  even  more  sensitive  than  milk  in 
transmitting  unpleasant  flavours. 

Butter  will  not  support  life  for  any  length  of  time  when  taken 
alone.  Carnivora  fed  upon  an  exclusive  diet  of  meat  and  fat  do  not 
grow  fat,  therefore  the  original  Banting  treatment  for  obesity  (see 
Obesity)  has  been  modified  by  Ebstein  and  others  by  the  free  addi- 
tion of  butter  to  the  diet.  Taken  in  connection  with  other  foods, 
however,  butter  is  a  highly  digestible  and  nutritious  food,  and  is 
often  fattening,  and  it  has  been  wittily  said  that  "  if  bread  is  the  staff 
of  life,  butter  is  its  golden  head." 

In  weak  stomachs  the  digestion  of  butter  is  improved  by  spread- 
ing it  thoroughly  in  thin  layers  upon  bread,  or  allowing  it  to  soak 
into  hot  toast.  It  is  thus  prevented  from  floating  about  in  the  man- 
ner which  coats  the  food  and  walls  of  the  stomach  and  retards  gastric 
secretion  (Brunton).  Most  persons  eat  about  an  ounce  a  day  of  but- 
ter, but  many  eat  double  that  quantity.  Its  annual  production  in  the 
United  States  exceeds  one  billion  pounds. 

The  use  of  oleomargarine  and  butterine  as  substitutes  for  butter 
are  described  under  the  heading  Fats  and  Oils  (see  pages  176,  177). 

4.  Buttermilk. — Buttermilk  is  the  residual  milk  left  after  churn- 
ing and  removing  the  fat.  It  is  usually  fed  to  pigs,  but  it  is  whole- 
some and  diuretic,  and  makes  a  capital  beverage  for  those  patients 
who  fancy  its  peculiar  sour  taste.  It  contains  albumin  and  finely 
coagulated  casein,  salts,  water,  and  sugar,  which  is  largely  converted 


86 


FOODS   AND   FOOD   PREPARATIONS. 


into  lactic  acid.  It  should  be  drunk  fresh,  for  it  soon  decomposes. 
Some  patients  can  digest  it  who  are  unable  to  take  ordinary  milk.' 
In  those  disorders  in  which  the  digestion  of  peptones  and  fats  is  poor 
it  is  often  well  borne,  and  it  contains  less  fat  than  skimmed  milk, 
over  which  it  jjossesses  but  little  advantage,  although  some  persons 
are  very  fond  of  it. 

It  is  of  especial  value  in  chronic  gastric  catarrh  with  atrophy  of 
the  gastric  glands  (Eulenburg).  A  "buttermilk  cure"  is  sometimes 
practised  after  the  manner  of  the  "whey  cure"  (see  pages  697,  698), 
but  buttermilk  cannot  long  be  depended  upon  as  an  exclusive  diet. 

5.  Cheese. — Cheese  is  the  separated  casein  of  milk,  which  in- 
cludes some  of  the  fat  and  salts.  There  are  many  varieties,  pre- 
pared in  different  ways,  but  the  two  chief  classes  are  hard  cheeses 
and  soft  cheeses,  the  former  being  pressed  and  salted.  Cheese  forms 
a  highly  nutritious  food  and  an  important  article  of  commerce.  In 
countries  where  meat  is  scarce  and  dear  the  peasantry  consume  large 
quantities  to  supply  the  nitrogenous  element  of  their  diet.  Weight- 
for-weight  cheese  contains  about  twice  as  much  proteid  as  meat 
(Parkes).  They  use  for  this  purpose  the  heavier,  less  highly  fla- 
voured cheeses.  The  wealthier  classes  eat  cheese  more  as  a  condi- 
ment, taken  after  meals,  and  therefore  they  require  higher  flavoured 
varieties,  which  please  the  palate  and  excite  the  secretion  of  gastric 
juice.  Eaten  in  moderation,  such  cheeses  are  an  aid  to  digestion. 
Taken  with  milk,  cheese  tends  to  reduce  the  size  of  the  coagulae  in 
the  stomach. 

About  250,000,000  pounds  of  cheese  are  annually  produced  in  the 
United  States  alone. 

The  kinds  of  cheese  differ  somewhat  in  composition,  but  in  gen- 
eral they  may  be  said  to  contain  from  35  to  55  percent  of  water  and 
from  10  to  20  per  cent  of  fats,  20  to  30  per  cent  of  casein,  and  about 
6  per  cent  of  salts. 

Cheese  is  rich  in  fat  or  in  flavour  according  as  it  is  made  from 
whole  or  skimmed  milk.  Cream  cheese  contains  about  77  per  cent 
of  fat,  and  the  highly  flavoured  Roquefort,  Edamer,  Cheshire,  and 
Emmenthaler,  or  Schweizer  cheeses  have  a  similar  quantity,  and  are 
nutritive  when  they  can  be  digested. 

Bauer's  analysis  of  cream  cheese  places  the  fats  much  lower,  and 
the  casein  is  also  at  a  minimum. 


Bauer  s  Analysis  of  Cream  Cheese 

Water. 

Nitrogenous 
matter. 

Fat. 

Extractives. 

Ash. 

Cream  cheese 

Whole  milk 

35-75 
46.82 
48. 02 

7.16 
27.62 
32.65 

30.43 

20.54 

8.41 

2.53 
2.97 
6.80 

4-13 
3-05 
4.12 

Skimmed  milk 

ANIMAL  FOODS. 


8^7 


Cheese  is  usually  prepared  from  sweet  milk.  The  coagulation  is 
accomplished  in  a  few  minutes  by  the  addition  of  the  ferment  rennin 
with  gentle  heat  (120°  F.).  The  heat  secures  firmer  coagulation. 
Casein  may  also  be  coagulated  by  acids.  A  little  salt  is  added ;  the 
curd  is  strongly  pressed  m  a  mould,  and  the  expressed,  fluid  is  called 
"whey."  The  curd  is  then  salted  and  dried  on  the  surface  by  fre- 
quent turning  in  the  air.  The  harder  cheeses  are  made  under  higher 
temperature  and  pressure.  Cheese  is  kept  for  a  time  to  "  ripen,"  by 
fermentation  or  decomposition.  If  the  decomposition  goes  too  far, 
it  develops  leucin  and  tyrosin.  The  casein  may  become  soluble  in 
water,  producing  soda  albuminate  and  peptones.  The  "  riper "  a 
cheese  the  greater  is  its  value  as  a  condiment. 

During  the  ripening  volatile  fatty  acids  are  evolved  from  the  fatty 
matter  present,  which  occasion  the  odour  and  flavour.  The  casein 
also  undergoes  change,  and  is  partially  converted  into  fat  (Foster). 
It  may  putrefy  and  evolve  ammonia,  or  even  become  poisonous. 
Ripening,  when  not  carried  too  far,  makes  cheese  more  friable,  and 
hence  more  digestible. 

Cream  cheese  is  fresh,  and  usually  not  ripened,  but  Neuchatel  is 
ripened. 

Pot  cheese  is  eaten  fresh  after  the  whey  has  been  expressed.  It 
contains :  Water,  60.27  per  cent ;  casein,  24.84  per  cent ;  fat,  7.33  per 
cent ;  ash,  4.02  per  cent ;  milk  sugar  and  lactic  acid,  3.54  per  cent. 

The  quality  of  cheese  depends  upon  the  richness  of  the  milk  in 
fat.  In  the  richest  cheeses  made  of  whole  milk,  such  as  Stilton, 
double  Gloucester,  Gorgonzola,  and  Roquefort,  cream  is  added. 
Single  Gloucester,  American,  and  similar  cheeses  are  made  from 
milk  from  which  the  cream  has  been  removed.  Dutch,  Suffolk,  and 
Parmesan  cheeses  are  also  made  from  skimmed  milk,  and  are  "poor." 
Being  nearly  pure  casein,  they  are  hard  to  digest  in  bulk.  These 
latter  varieties  keep  well,  and  become  hard  enough  to  be  grated. 
Fatty  matter  separates  the  flocculi  of  casein  and  makes  cheeses  soft, 
friable,  and  rich,  but  they  sooner  decay. 

The  two  soft  cheeses  most  used  in  this  country  are  Camembert 
and  Brie. 

Camembert  is  a  cheese  made  of  whole  milk,  which  is  very  care- 
fully dried  under  regulated  temperature  It  requires  three  or  four 
weeks  to  ripen. 

Brie  cheeses  are  manufactured  in  three  grades  of  richness,  accord- 
ing to  whether  the  milk  is  whole,  partly  skimmed,  or  skimmed. 

Roquefort  is  a  hard  cheese  made  in  the  department  of  Aveyron 
from  goat's  milk,  partly  skimmed  and  coagulated  with  rennin.  The 
curd  is  then  pressed  for  half  a  day,  dried  for  ten  or  twelve  days,  and 
ripened  in  caves.  This  cheese  is  streaked  with  bluish  lines,  which  are 
formed  by  the  addition  of  a  mould  which  grows  on  stale  rye  bread. 


88  FOODS  AND  FOOD  PREPARATIONS. 

Gruy^re  was  originally  a  hard  Swiss  cheese,  but  is  now  made  also 
in  France  and  elsewhere.  It  is  dry,  aerated  with  large  holes,  and  it 
can  be  crumbled.  It  is  manufactured  in  three  grades,  according  to 
the  degree  of  skimming  of  the  milk,  and  the  curd  is  cooked  a  short 
time  before  it  is  pressed.     It  has  a  somewhat  saltish  taste. 

Gorgonzola  {stracchino)  is  a  Piedmontese  cheese  made  with  hot 
and  cold  curds  from  two  milkings,  which  do  not  perfectly  unite,  but 
which  form  minute  interstices  in  which  a  green  mould  called  "  pars- 
ley "  grows  and  imparts  a  high  flavour  (Clark).  The  curd  is  hung 
in  hempen  cloths  to  ferment.     It  is  well  salted. 

In  the  United  States  most  of  the  cheese  manufactured  is  of  the 
common  sort  called  ''American  cheddar,"  but  Neuchatel,  Stilton, 
pineapple,  and  other  more  highly  flavoured  varieties  are  also  pro- 
duced. An  imitation  cheese  is  also  prepared  from  a  mixture  of  one 
part  lard  and  two  or  three  parts  milk,  mixed  or  emulsionised  at  140° 
F.  This  emulsion  is  then  added  with  buttermilk  to  skimmed  milk, 
so  that  the  finished  product  contains  about  14  per  cent  of  lard  (Cald- 
well). 

Toasted  cheese  is  one  of  the  most  indigestible  articles  of  diet, 
unless  the  cheese  is  new,  "  poor,"  and  cut  thin.  "  Welch  rarebits  " 
are  notoriously  difficult  of  digestion,  although  highly  nutritious  when 
absorbed.  It  is  an  old  saying  of  such  cheese  that  it  is  "gold  in  the 
morning  but  lead  at  night." 

Certain  low  organisms,  ifioulds,  fungi,  etc.,  flourish  in  cheese  and 
make  it  very  irritant  to  the  stomach.  Such  are  Iht  Aspergillus  glaucus 
and  Sporendonetim  casei,  both  of  which  give  a  red  colour,  the  cheese 
mite  {Acanis  domesticus)  and  the  maggots  of  a  fly  [Piop/iilia  casei). 
Bad  cheese  has  been  known  to  develop  poisonous  symptoms  (see 
Ptomaine  Poisoning)  resembling  those  of  poisoning  by  sausage 
meat. 

6.  Whey. — Whey  is  the  residuum  of  milk  from  which  the  casein 
and  fat  have  been  removed  as  cheese  by  the  action  of  rennin  or  other- 
wise. It  contains,  in  addition  to  water,  salts,  especially  of  potassium, 
a  little  lactalbumin,  and  lactose.  It  is  apt  to  turn  sour,  but  is  fairly 
digestible  even  then,  and  its  taste  may  be  disguised  by  the  addition 
of  nutmeg  and  sugar. 

It  makes  a  palatable,  mildly  diuretic  drink,  which  is  enjoyed  by 
some  invalids.  In  Europe  several  "whey  cures  "  have  been  estab- 
lished for  the  treatment  of  renal  disease,  dropsical  affections,  etc., 
but  whey  is  not  in  any  sense  a  specific,  and  its  dietetic  value  is 
greatly  overrated. 

Yeo  gives  the  following  simple  directions  for  the  preparation  of 
whey  for  invalids:  Boil  a  pint  of  milk  with  one  to  two  teaspoonfuls 
of  lemon  juice;  strain  in  muslin,  and  express  all  fluid  from  the  curd. 
Break  the  curd  up  first,  and  much  fat  and  some  finely  divided  casein 


ANIMAL   FOODS. 


89 


will  go  into  whey.     Add  beef  tea  or  milk  juice,  or  egg  yolk  in  hot 
water. 

Eggs. 

About  nine  billion  eggs  are  produced  annually  in  the  United  States 
(Clark).  Eggs  contain  all  the  ingredients  necessary  to  support  life 
and  develop  the  organism.  Like  milk,  they  constitute  a  complete 
food,  for  out  of  an  egg  the  entire  structure  of  the  bird — its  bones, 
nerves,  muscles,  viscera,  and  sometimes  even  feathers — are  devel- 
oped previous  to  hatching.  The  inner  portion  of  the  shell  is  dis- 
solved by  phosphoric  acid  to  furnish  phosphates  for  the  bones. 

The  average  weight  of  a  hen's  egg,  according  to  Bauer,  is  50 
grammes,  divided  as  follows:  Shell,  7;  white,  27;  yolk,  16  grammes. 

Composition  of  a  Hens  Egg  (Lawes  and  Gilbert). 

Fresh  weight 1.8      ounce. 

Dry  weight 0.45        " 

Fat 0.198      " 

Mineral  matter 0.025      " 

Nitrogen o .  036      " 

Carbon 0-275      " 

Or  in  percentage : 

Water 70. 00  per  cent. 

Dry  matter 30.00       " 

100 .  00  per  cent. 

Nitrogen 2 .00  per  cent. 

Carbon 17-52        " 

The  shell  of  the  egg  weighs  about  one  hundred  grains.  An  egg 
consists  approximately  of — 

Shell — 10  parts Carbonate  of  lime. 

Yolk — 30  parts  :     Proteid 16.00  per  cent. 

Fats 30-70       " 

Salines 1.30 

Water 5200 

100.00  per  cent. 

White— 60  parts  :  Proteid 20.40  per  cent. 

Salines i-<x) 

Water 78- 00       " 

Total,  100  parts 100.00  per  cent. 

If  the  absorption  of  eggs  from  the  intestine  is  delayed,  decom- 
position ensues  with  production  of  sulphuretted  hydrogen  and  am- 
monia, which  cause  considerable  gastro-enteric  disorder.  The  yolk 
of  egg  is  particularly  responsible  for  this.  It  is,  therefore,  a  matter 
of  great  importance  to  serve  only  eggs  which  are  absolutely  fresh 
to  invalids.     No  egg  having  an  odour  of  stale,  old  straw  should  ever 


90 


FOODS   AND   FOOD   PREPARATIONS. 


be  offered.     There  are  two  simple  methods  by  which  the  nurse  may 
test  the  freshness  of  an  egg: 

1.  Hold  the  egg  between  the  hands  so  that  the  light  of  a  candle 
shines  through  it.  If  fresh,  it  is  more  transparent  in  the  centre;  if 
stale,  at  the  ends. 

2.  Make  a  solution  of  one  tablespoonful  of  common  salt  in  ten  of 
water.     A  good  egg  sinks  in  this  brine,  a  bad  one  floats. 

With  some  persons  eggs  have  a  slight  aphrodisiac  effect,  and 
they  also  promote  costiveness.  They  should  not  be  eaten  in  the 
following  diseases  :  Flatulent  dyspepsia,  gastric  dilatation,  or  any 
form  of  severe  gastric  derangement,  severe  acute  or  chronic  Bright's 
disease. 

Raw  Eggs. — Whole  raw  eggs  are  very  popular  in  dietetics  at 
present,  and  they  are  often  prescribed  when  a  nutritious,  highly  con- 
centrated diet  is  desired,  as  in  cases  of  tuberculosis,  some  forms  of 
anaemia,  and  various  wasting  diseases;  sometimes  from  eight  to  ten 
or  twelve  are  given  daily  if  they  can  be  digested.  They  may  be 
advantageously  combined  for  such  purposes  with  milk  and  salt  or 
cod-liver  oil,  meat  broths,  soups,  and  purees.  Beaten  white  of  egg 
may  be  added  to  coffee,  cocoa,  wine,  cream,  or  sweetened  water. 

Eggnog  is  very  nutritious,  and  is  extensively  prescribed  in 
some  non-febrile  diseases,  especially  for  the  forced  alimentation  of 
phthisis  and  melancholia,  and  there  are  occasional  cases  of  bilious 
habit  in  which  eggs  can  only  be  digested  when  beaten  in  wine,  but 
the  combination  of  egg,  milk,  and  sugar  with  alcohol,  which  consti- 
tutes eggr^og,  is  very  apt  to  produce  nausea  and  vomiting  in  a  feeble 
stomach,  particularly  in  fever.  For  this  reason  whole  eggs  are  unfit 
for  fever  patients,  and  if  eggs  are  employed  at  all  for  them,  the 
whites  only  should  be  used,  prepared  in  the  manner  described  in  the 
following  section  : 

Egg  Albumen,  when  eaten  raw  or  almost  raw  and  properly 
diluted  with  milk  or  water,  is  well  absorbed.  It  may  also  be  pre- 
digested,  and  it  should  be  flavoured  with  lemon  juice,  or  sherry  or 
other  wine,  coffee,  cocoa,  cream,  and  sweetened  water ;  otherwise  it 
is  tasteless  and  disagreeable,  and  but  few  can  continue  to  eat  it  in 
any  considerable  quantity.     (See  Receipts,  Preparations  of  Eggs.) 

Egg  albumen  is  used  by  Ewald  to  prepare  fresh  albuminate 
of  iron.  He  adds  two  tablespoonfuls  of  a  solution  of  one  part 
of  white  of  egg  to  two  of  water  to  a  teaspoonful  of  a  two-  or 
three-per-cent  solution  of  ferric  chloride.  To  be  taken  through  a 
tube. 

The  Cooking  of  Eggs. — Albumen,  or  the  "  white  "  of  an  egg  is 
greatly  altered  by  processes  of  cooking.  At  about  134°  F.  delicate 
fibrillae  of  coagulated  albuminous  material  begin  to  stretch  through 
the  substance,  and  they  increase  with  the  temperature  up  to  160°  F. 


ANIMAL   FOODS. 


91 


The  fibrillae  are  so  numerous  that  the  entire  mass  is  coagulated,  but 
is  still  of  a  soft  or  gelatinous  consistence. 

It  has  been  observed  by  Tarchnoff  that  the  coagulum  thus  formed 
in  the  eggs  of  birds  which,  like  the  chick,  are  hatched  with  feathers, 
becomes  white  and  opaque,  whereas  that  of  the  eggs  of  birds  which, 
like  the  plover,  are  hatched  without  feathers,  is  more  transparent. 
If  the  coagulated  albumen  is  heated  still  further,  it  becomes  more 
and  more  dense,  hard,  dry,  and  brittle.  When  heated  beyond  the 
boiling  point,  or  212°  F.,  it  forms  a  very  tenacious,  gluey  substance, 
which  can  be  used  as  a  cement  for  mending  broken  china. 

Eggs  baked  in  puddings  or  in  any  other  manner  form  one  of 
the  most  insoluble. varieties  of  albumen  possible.  A  raw  egg  is  ordi- 
narily digested  in  the  stomach  in  one  and  a  half  hour,  but  a  baked 
egg  requires  from  three  and  a  half  to  four  hours. 

These  statements  are  made  to  especially  emphasise  the  necessity 
of  cooking  eggs  at  a  proper  temperature,  for  while  still  soft  and 
gently  coagulated  at  about  1605"  F.  (or  52°  F.  below  the  boiling  point), 
the  albumen  is  very  easily  digested,  but  when  "  hard  boiled  "  it  is  ex- 
ceedingly indigestible.  One  can  be  convinced  of  this  by  attempting 
to  dissolve  the  whites  of  eggs  cooked  in  different  degree  by  the 
addition  to  them  in  a  test  tube  of  a  little  pepsin  and  hydrochloric 
acid. 

The  principle  involved  in  this  account  of  the  cooking  of  an  egg 
is  further  illustrated  by  the  process  of  overcooking  beefsteak. 
When  strong  heat  is  too  long  applied  in  the  process  of  broiling,  the 
albumin  of  the  meat  becomes  dried,  shrivelled,  and  comparatively 
tasteless;  and  eggs  cooked  for  persons  with  delicate  digestions,  in- 
stead of  being  "  boiled  "  in  water  at  212°  F.,  should  be  placed  in 
water  at  a  temperature  between  170°  and  180°  F.,  and  immersed  for 
fully  ten  minutes,  at  the  end  of  which  time  they  will  be  found  of  a 
uniform  gelatinous  consistence,  very  palatable,  and  not  too  tough  to 
be  readily  acted  upon  by  the  gastric  juice.  If  a  cooking  thermome- 
ter is  not  at  hand,  the  water  may  be  previously  brought  to  the  boiling 
point  and  then  set  aside,  when  in  a  moment  or  two  it  will  cool  to 
the  proper  temperature.  This  should  be  a  little  above  the  coagula- 
tion point  of  the  egg  albumen  (160°  F.),  because  the  process  of  rais- 
ing the  temperature  of  the  egg  is  a  slow  one,  and  the  water  loses 
heat  in  warming  the  egg  (Williams).  Eggs  cooked  in  this  manner 
are  found  to  have  the  yolks  more  firmly  coagulated  than  the  white, 
which  remains  quite  tender.  A  practical  way  of  attaining  the  above 
result  is  to  pour  a  quart  of  recently  boiled  water  over  two  eggs  in 
a  bowl  and  let  them  stand  for  ten  or  twelve  minutes. 

Another  excellent  way  to  cook  an  egg,  as  suggested  by  Henry, 
is  to  immerse  a  teacup  in  boiling  water  until  it  becomes  thoroughly 
heated:     It  is  then  removed  and  the  -egg  is  broken  and  dropped 


Q2  FOODS  AND  FOOD  PREPARATIONS. 

into  it,  and  the  cup  may  be  wrapped  in  a  cloth.  Sufficient  heat  is  re- 
tained  by  it  to  cook  the  egg  without  water  and  remove  any  raw  taste. 

The  yolk  really  coagulates  at  a  lower  temperature  than  the  white, 
although  as  eggs  are  commonly  cooked  it  does  not  have  an  oppor- 
tunity to  coagulate  first.  The  former  is  composed  of  albumin  and 
casein  with  fat  (Lehmann).  In  the  ordinary  rapid  cooking  of  eggs 
in  boiling  water  the  white  is  firmly  set  before  there  is  time  for  the 
temperature  of  the  interior  of  the  egg  to  be  thoroughly  raised,  and 
consequently  the  yolk  is  softer  than  the  white.  The  shell  of  the  egg 
facilitates  the  process  of  slow  cooking  of  the  albumen  by  protecting 
the  interior  and  preventing  the  escape  of  the  contents  by  solution, 
just  as  in  the  cooking  of  fish  or  flesh  in  water,  the  latter  should 
be  hot  enough  to  immediately  form  an  external  coagulum  of  albu- 
men sufficiently  dense  to  prevent  the  diffusion  of  albuminous  mate- 
rial and  salts  into  the  water. 

Custards  composed  largely  of  eggs,  although  unfit  for  active 
fever,  are  very  useful  adjuncts  to  a  convalescent  dietary  in  recovery 
from  typhoid  fever  or  other  acute  diseases. 

In  the  making  of  omelettes  and  "  scrambled  "  eggs  the  white  is 
thoroughly  mixed  with  the  yolk,  and  the  egg  is  more  digestible  than 
when  fried  or  cooked  so  much  that  the  albumen  is  hard. 

Preservation  of  Eggs. — Eggs  decompose  from  the  admission 
of  germs  through  their  porous  shells.  To  prevent  this  occurrence  it 
is  necessary  to  protect  the  eggs  from  contact  with  air.  They  may  be 
coated  with  varnish,  tin  foil,  butter,  or  any  fat  or  oil  not  liable  to  be- 
come rancid.  A  2-  or  3-per-cent  solution  of  salicylic  acid  may  be 
added  to  the  oil.  Packing  in  sawdust  also  excludes  the  air  to  a  slight 
extent.  Lime  with  cream  of  tartar  preserves  eggs,  but  alters  their 
taste. 

Eggs  are  also  preserved  by  drying,  canning,  and  similar  processes, 
when  designed  for  shipment  upon  long  voyages. 

Meats. 

The  Consumption  of  Meat. — The  universal  consumption  of 
meat  by  civilised  man  is  of  more  recent  origin  than  is  generally  sup- 
posed. McCulloch  states  (Statistical  Account  of  the  British  Em- 
pire, vol.  ii,  p.  502)  that  "  so  late  as  1763  the  slaughter  of  bullocks  for 
the  supply  of  the  public  markets  was  a  thing  wholly  unknown  even  in 
Glasgow,  though  the  city  had  then  a  population  of  thirty  thousand." 

In  the  past  decade  or  two  the  consumption  of  meat  has  increased 
enormously,  especially  in  England,  owing  to  the  development  of 
cheap  refrigerating  processes,  canning,  and  increased  facilities  of 
transportation  of  live  cattle.  The  beef  from  Australian  cattle  is  ob- 
tainable in  London,  and  that  of  Texan  cattle  in  New  York  in  a  state 
of  perfection  and  cheapness  which  far  exceeds  that  of  animals  raised 


ANIMAL  FOODS. 


93 


close  at  hand.  There  is  a  popular  belief  that  the  eating  of  meat  in- 
creases both  bodily  vigour  and  mental  capacity,  and  that  a  man  fed 
upon  animal  food  is  livelier,  keener,  and  stronger  than  the  exclusive 
vegetarian.  (See  Animal  and  Vegetable  Foods  Compared,  p.  22.) 
This  comparison  may  not  hold  in  all  cases,  nor  with  all  people  and 
tribes  of  man — as,  for  example,  the  Japanese  and  many  African  tribes 
—but  it  applies  very  well  to  those  who  have  to  meet  the  exigencies 
of  advanced  civilisation.  Liebig,  in  extolling  the  advantages  of  a 
liberal  meat  diet,  wrote  :  "  It  is  certain  that  three  men,  one  of  whom 
has  had  a  full  meal  of  meat  and  bread,  the  second  cheese  or  salt 
fish,  and  the  third  potatoes,  regard  a  difficulty  which  presents  itself 
from  entirely  different  points  of  view." 

It  is  true,  however,  that  too  much  meat  is  eaten  by  many  persons 
for  maintenance  of  the  best  health. 

Very  large  quantities  of  meat — much  more  than  is  necessary  for 
sustenance — are  absorbed  when  eaten,  although  a  few  undigested 
muscle  fibres  may  appear  in  the  stools. 

A  meat  diet,  if  long  continued,  tends  to  produce  scurvy,  and  the 
absence  of  meat  favours  the  occurrence  of  anaemia  in  many  persons. 
In  general,  those  diseases  in  which  an  exclusive  meat  diet,  or  a  diet 
composed  almost  exclusively  of  animal  food,  with  perhaps  a  minimum 
of  dry  bread,  is  found  beneficial,  are  the  following:  Flatulent  dys- 
pepsia, chronic  gastritis  and  gastric  catarrh  and  dilatation,  diabetes, 
intestinal  dyspepsia,  phosphaturia,  obesity,  and  some  cases  of  chronic 
dysentery.  Meat  should  also  enter  largely  into  the  diet  of  consump- 
tives and  anaemic  subjects. 

It  is  well  to  reduce  or  prohibit  the  consumption  of  meat  in  acute 
and  chronic  Bright's  disease,  gout  and  rheumatism,  lithaemia,  and 
oxaluria. 

Composition  of  Meats. — Meat  from  any  animal  is  composed  of 
muscular  fibres,  but  it  necessarily  contains  those  structures  which 
were  intimately  associated  with  them,  such  as  connective  tissues, 
blood  vessels,  nerves,  and  lymphatic  vessels,  and  more  or  less  adipose 
tissue.  Meat  which  is  very  fat  contains  comparatively  little  water, 
as  well  as  less  nitrogenous  matter  than  lean  meat. 

In  one  hundred  parts  of  flesh  there  are,  according  to  Schloss- 
berger  and  v.  Bibra  : 


Ox. 

Pig- 

Man. 

Fowl. 

Carp. 

Water. 

77-50 

22.50 

2.20 

1.30 

1.50 

17-50 

78.30 

21.70 

2.40 

0.80 

.!:'° 

ib.Si 

74-45 

25-55 

1-93 

«.07 

3-71 
2.30 

15-54 

77-30 

22.7 

3-0 

1.2 

1.4 

79.78 

Solids 

20.22 

Soluble  albumin,  colouring  matter. . . 
Gluiin 

2.35 
1.98 

Alcoholic  extract 

3-47 

Fats 

I. II 

Insoluble  albumin,  blood  vessels,  etc. 

13-31 

94 


FOODS   AND   FOOD    PREPARATIONS. 
Composition  of  Various  Meats  (Moss). 


Constituents. 


Nitrogenous  matters , 

Fat 

Carbohydrates 

Saline  matters 

Non-nitrogenised     organic    matters, 

and  loss 

Water 

Total 

Constituents. 

Nitrogenous  matters 

Fat 

Carbohydrates 

Saline  matters 

Non-nitrogenised     organic    matters, 

and  loss 

Water 

Total 


Lean 

beef 

(Pavy). 

Fat 

beef 

(Pavy). 

Lean 
mutton 
(Pavy). 

Fat 
mutton 
(Pavy). 

19-3 
3-6 

14.8 
29.8 

18.3 
4.9 

12.4 
3I-I 

5-1 

4-4 

4.8 

3-5 

72.0 

5I-0 

72.0 

53-0 

lOO.O 

100. 0 

100. 0 

100. 0 

Veal 
(Pavy). 


16.5 
15-8 

4-7 


63.0 


Fat 

pork 

(Pavy). 

Dried 
bacon 
(Pavy). 

Calves' 

liver 
(Payen). 

Fois 

gras 

(Payen). 

9.8 
48.9 

2.3 
39-0 

8.8 
73-3 

2.9 
15-0 

20.10 
5-58 
0.45 
1.54 

72.33 

13-75 

54-57 

6.40 

2.58 

20.70 

100. 0 

100. 0 

100.00 

100.00 

Sheep's 
kidneys 
(Payen). 


17-250 
2.125 


1-325 
78.200 


Raw  Meats. — There  is  a  prevalent  fashion  at  present  of  pre- 
scribing raw  meat,  and  in  some  diseases,  such  as  dysentery  or  chronic 
gastritis,  it  is  useful,  but  it  should  not  be  given  with  the  idea  that  it 
possesses  any  special  curative  virtue  from  the  fact  of  being  raw. 
Beef,  mutton,  and  ham  are  all  eaten  in  this  condition.  Meat  is  dis- 
tasteful to  most  persons  in  this  state  and  soon  palls  upon  the  appe- 
tite, and  may  excite  positive  loathing.  There  is  a  natural  aversion 
to  raw  flesh  among  even  the  lowest  tribes  of  man,  who  only  consume 
their  meat  raw  from  excessive  hunger  or  when  fire  is  unobtainable. 
Even  the  primitive  Australian  savage  codks  his  reptiles  and  worms. 
Raw  meat  has  no  advantage  either  in  digestibility  or  nutrient  power 
over  moderately  cooked  or  "  underdone  "  meat.  Some  danger  has 
been  attributed  to  eating  raw  meat  on  account  of  the  possibility  of 
acquiring  intestinal  worms  through  it,  but  the  fear  of  this  is  much 
exaggerated. 

On  the  other  hand,  meat  is  easily  altered  and  made  innutritious 
by  prolonged  cooking.     Overdone  meat  is  indigestible  and  tasteless. 

If  meat  is  too  long  boiled  it  becomes  insipid  and  useless  as  an 
aliment,  and  the  resulting  soup  is  not  a  full  substitute  for  it.  Meat 
should  never  be  cooked  during  rigor  mortis. 

Hall  and  Kane  both  declared  that  in  their  arctic  experience 
fresh  raw  meat  was  a  preventive  of  scurfy,  but  that  cooked  meat 
was  not. 


ANIMAL   FOODS. 


95 


Digestibility  of  Meats. — Among  the  circumstances  which  affect 
the  digestibility  and  nutrient  power  of  meats  are  the  age  at  which 
the  animals  eaten  were  killed,  and  the  care  bestowed  upon  them  in 
feeding,  shelter,  and  transportation.  Animals  which  have  been  under- 
fed, ill-treated,  and  worried  yield  very  inferior  meat. 

Almost  all  meat  is  tougher  immediately  after  killing,  and  improves 
on  being  kept  for  a  day  or  two.  Violent  exercise  is  believed  to  in- 
crease the  tenderness  of  the  meat  of  hunted  animals. 

In  general,  the  flesh  of  young  is  more  digestible  than  that  of  old 
animals,  provided  they  are  not  still  suckling. 

It  would  be  convenient  if  meats  and  animal  foods  of  all  kinds 
could  be  arranged  in  a  table  of  comparative  digestibility,  but  such 
tables  are  necessarily  inaccurate,  if  not  actually  misleading,  owing 
to  the  great  variations  produced  by  the  character  of  the  particular 
samples  of  food  used,  by  the  time  and  manner  of  cooking,  by  the 
condition  of  the  digestive  organs,  and  by  personal  idiosyncrasy.  No 
two  tables  of  this  kind  given  by  different  authors  are  found  to  agree 
in  all  respects. 

The  following  table  is  offered  as  an  average  of  the  ease  of  diges- 
tibility of  animal  foods,  the  time  required  for  the  completion  of  gas- 
tric digestion  being  the  chief  standard,  but  some  foods  may  be  well 
enough  digested  although  they  require  half  an  hour  or  so  longer  time 
than  others. 

Table  of  Comparative  Digestibility  {commencing  with  the  Most  Digestible, 
and  ending  with  the  Least  Digestible  of  Meats  and  Other  Common  Ani- 
mal Foods). 


Oysters. 

Soft-cooked  eggs. 
Sweetbread. 

White  fish,  boiled  or  broiled,  such  as 
bluefish,  shad,  red  snapper,  weakfish,  smelt. 
Chicken,  boiled  or  broiled. 
Lean  roast  beef  or  beefsteak. 
Eggs,  scrambled,  omelette. 
Mutton,  roasted  or  boiled. 
Squab,  partridge. 
Bacon. 

Roast  fowl,  chicken,  capon,  turkey. 
Tripe,  brains,  liver. 


Roast  lamb. 

Chops,  mutton  or  lamb. 

Corned  beef. 

Veal. 

Ham. 

Duck,  snipe,  venison,  rabbit,  and  other 
game. 

Salmon,  mackerel,  herring. 

Roast  goose. 

Lobsters  and  crabs. 

Pork. 

Smoked,  dried,  or  pickled  fish  and 
meats  in  general. 


The  table  given  below  is  published  by  E.  Jessen  as  the  result  of 
giving  test  meals  of  single  articles  of  food.  The  stomach  was  first 
cleansed  and  emptied  by  siphonage,  then  a  hundred  grains  of  meat 
were  introduced  with  eight  ounces  of  water.  Samples  of  the  di- 
gested stomach  contents  were  from  time  to  time  withdrawn,  and  the 
complete  disappearance  of  all  muscular  fibre  when  examined  by  the 
microscope  occurred  as  follows ; 
9 


p6  FOODS   AND   FOOD   PREPARATIONS. 

Beef,  raw,  chopped  fine 2  hours. 

Beef,  half  cooked 2^  " 

Beef,  well  cooked 3  " 

Beef,  thoroughly  roasted 4  " 

Mutton,  raw 2  " 

Veal,  cooked 2^  " 

Pork,  cooked 3  " 

These  estimates  fall  somewhat  below  those  of  other  writers,  and 
for  comparison  he  gives  the  time  for  digestion  of  six  hundred  cubic 
centimetres  of  raw  cow's  and  goat's  milk  as  three  and  a  half  hours, 
and  that  of  boiled  milk  as  four  hours,  which  is  too  long. 

Bauer  places  the  order  of  easiest  digestibility  of  meats  in  delicate 
stomachs  as  follows:  Young  poultry  (fowls  or  pigeons),  veal,  game, 
and  beef. 

Beef. — The  composition  of  beef  varies  with  the  feeding  of  the 
animal.  A  young  steer  from  four  to  five  years  old  furnishes  the 
best  meat.  If  the  animal  is  lean  the  meat  may  yield  from  70  to  75 
per  cent  of  water  and  about  20  per  cent  of  nitrogenous  material, 
with  2  or  3  per  cent  of  fat,  but  if  very  fat  when  killed,  the  per- 
centage of  both  water  and  nitrogenous  material  is  considerably  re- 
duced, while  that  of  the  fat  may  be  as  high  as  25  per  cent,  or  even 
more. 

Beef  fat  is  composed  of  glycerides  of  fatty  acids.  It  melts  at 
from  41°  to  50°  C.  Stearic  and  palmitic  acids  are  present  in  the 
proportion  of  three  to  one  of  oleic  acid. 

The  equivalent  of  beef  is  sometimes  stated  in  terms  of  other 
foods.  A  pound  of  lean  beef  is  believed  to  equal  in  nutrient  value 
two  pints  of  milk  and  about  three  eggs,  but  these  are  only  approxi- 
mate figures. 

Fresh  beef  can  be  eaten  longer  continuously  than  any  other  kind 
of  meat.  In- this  respect  it  resembles  bread  and  rice.  Attempts 
have  sometimes  been  made  on  wagers  to  eat  quail  or  partridge  three 
times  a  day  consecutively  for  a  month,  but  disgust  is  sure  to  follow 
after  a  week  or  two,  no  matter  how  much  such  food  is  varied  in  the 
cooking,  and  by  the  end  of  that  time  it  may  excite  extreme  loathing, 
and  even  nausea  and  vomiting. 

Chipped  beef  is  prepared,  like  corned  beef,  by  pickling  for  a 
month,  when  it  is  smoked  for  two  days  and  dried  for  a  fortnight, 
after  which  it  is  sliced  thin  by  machinery  and  is  ready  for  packing. 

Beef  Preparations  for  the  Sick. — Beef  is  so  important  a  food 
for  well  and  sick  alike  that  many  attempts  have  been  made  to  im- 
prove its  digestibility  for  the  latter. 

Most  of  these  efforts  are  aimed  at  concentrating  the  meat  by  re- 
moving all  indigestible  connective-tissue  fibre,  the  muscle  sheaths, 
sarcolemma,  and  blood  vessels. 


ANIMAL   FOODS. 


97 


In  some  cases  the  process  of  concentration  is  carried  still  further 
and  water  is  driven  off  by  evaporation,  or  some  of  the  active  prin- 
ciples of  the  meat  are  extracted  and  condensed.  Sometimes  the 
meat  is  predigested.  Different  meats  may  be  prepared  in  these  ways, 
but  the  best  lean  beef  free  from  coarse  fibre  is  usually  preferred. 

It  is  impossible  within  the  limits  of  this  work  to  even  name  all 
the  meat  extracts,  pov.ders,  etc.,  that  have  been  produced,  but  a 
few  of  the  typical  ones  which  are  most  in  use  will  be  described 
below. 

It  was  long  ago  shown  by  Schiff  that  many  fluid  substances,  such 
as  meat  extract,  soups,  peptones,  and  even  vegetable  purees  when 
taken  at  the  commencement  of  a  meal,  on  being  absorbed  into  the 
blood,  favour  the  flow  of  gastric  juice.  This  is  true  also  of  peptones 
injected  into  the  rectum,  so  the  effect  is  not  wholly  due  to  local  stim- 
ulation of  the  inner  surface  of  the  stomach. 

Much  attention  has  of  late  been  given  to  the  predigestion  of 
meat,  and  especially  to  the  production  of  albumoses,  which  are  more 
soluble  and  assimilable  than  undigested  meat  albumin,  and  which  are 
said  to  possess  greater  nutritive  property  than  peptones. 

The  beef  extracts  made  in  this  country  usually  have  a  less  dis- 
agreeable taste  and  odour,  and  are  lighter  in  colour  than  those  made 
of  South  or  Central  American  beef. 

In  general,  about  three  grammes  of  a  meat  extract  constitute  a 
good  soup  ration,  and  such  preparations  are  often  valuable  for  addi- 
tion to  invalid  soups  and  broths  when  .thickened  with  eggs,  rice,  sago, 
pearl  barley,  macaroni,  ground  toast,  etc. 

The  preparations  of  meat  for  the  sick  are  both  solid  and  fluid. 

Solid  Meat  Preparations. — Scraped  meat  is  best  made  from 
tender  beefsteak,  broiled  for  a  few  minutes  over  a  brisk  fire,  but  rare 
roast  beef  or  mutton  chops  may  be  used.  With  a  dull  knife  or  an 
iron  spoon  the  pulp  is  scraped  out.  The  indigestible  and  less  nutri- 
tious connective-tissue  sheaths  of  the  muscle  fasciculi  are  broken 
and  left  behind,  while  the  fibres  themselves  (or  their  myosin)  are  ob- 
tained in  the  form  of  a  soft  unirritating  mass  which  is  readily  acted 
upon  by  the  gastric  juice.  The  pulp  maybe  ru'n  through  a  sieve.  It 
is  then  salted,  and  it  may  be  made  into  little  balls  and  browned  just 
before  eating.  This  is  done  by  placing  the  balls  on  a  hot  frying  pan, 
which  is  not  greasy,  and  turning  them  over  so  that  the  outside 
becomes  well  seared.  They  should  then  be  set  aside  on  a  cooler 
part  of  the  stove  or  oven  and  allowed  to  remain  until  the  raw  red 
colour  of  the  interior  turns  slightly  to  drab. 

Some  patients  prefer  to  eat  the  meat  scarcely  cooked,  spread  as 
a  sandwich  between  thin  slices  of  bread  and  butter.  This  meat 
(without  the  bread)  may  be  fed  to  infants  in  their  second  year,  and 
the  meat  balls  and  sandwiches  are  invaluable  in  the  treatment  of 


Ag  FOODS  AND  FOOD  PREPARATIONS. 

chronic  gastritis,  dilatation   of  the   stomach,  typhoid  convalescence, 
and  other  affections. 

Mosquera's  beef  meal  \%  made  by  digesting  fresh  tender  lean  beef 
with  pineapple  juice  until  the  muscle  fibre  is  almost  completely  con- 
verted into  peptones.  After  digestion  the  preparation  is  desiccated. 
Chittenden's  analysis  of  this  meal  shows  it  to  contain  90  per  cent  of* 
nutriment,  13  per  cent  of  which  is  fat  and  77  per  cent  is  proteid.  Of 
the  latter,  almost  half  consists  of  albumoses  and  peptones  fit  for 
prompt  absorption.  The  remaining  portion  is  believed  to  be  in  a 
condition  in  which  it  is  more  digestible  than  plain  meat. 

The  beef  meal  is  tasteless  and  odourless,  which  are  decided  ad- 
vantages, as  it  can  be  flavoured  according  to  preference. 

It  should  be  salted,  and  it  may  be  added  to  broths  and  soups.  D. 
D.  Stewart  advises  its  use  with  equal  parts  of  sugar  and  cocoa.  This 
mixture  is  added  to  hot  milk. 

Mosquera's  beef  Jelly  \s  made  in  a  similar  manner,  but  is  evaporated 
to  the  consistence  of  a  solid  extract.  Analysed  by  Ludwig,  it  was 
found  to  contain  only  3  per  cent  of  insoluble  material,  and  of  the 
soluble  portion  53  per  cent  consists  of  albuminoids  which  were  nearly 
all  peptones. 

It  is  of  pleasant  tast  and  odour,  and  is  highly  nutritious.  Dis- 
solved in  boiling  water,  it  may  be  given  alone  with  a  pinch  of  salt 
or  added  to  re-enforce  any  broth,  gruel,  consomme,  beaten  eggs,^  or 
milk.  The  beef  jelly  is  even  more  digestible  than  the  meal.  It  is 
sometimes  combined  with  coco.a. 

The  beef  meal  and  jelly  are  both  excellent  for  use  in  gastritis, 
gastric  catarrh,  ulcer,  and  carcinoma,  and  many  forms  of  enfeebled 
assimilation. 

Benger's  peptonised  beef  Jelly  \s  another  good  beef  preparation  much 
in  vogue  in  England  for  the  same  purposes  as  Mosquera's  prepara- 
tions. It  may  be  taken  cold  or  dissolved  in  hot  water  as  a  concen- 
trated beef  tea,  representing  a  large  amount  of  meat  fibre.  It  is  a 
useful  stimulant  for  the  aged  who  have  feeble  digestive  power.  It 
may  be  given  to  them  in  teaspoonful  doses. 

Darby  s  fluid  meat  is  a  moist  extract  which  has  a  strong  meaty 
taste.  It  can  be  eaten  spread  on  thin  bread  and  butter  or  cracker, 
or  it  may  be  dissolved  in  hot  water. 

Powdered  beef  is  made  as  follows  : 

Chop  lean  beef  into  small  pieces,  dry  on  a  water  bath  or  in  an 
oven  with  a  slow  fire,  and  powder  in  a  coffee  mill  or  with  a  machine 
constructed  for  the  purpose.  Do  not  overdry.  This  powder  can  be 
mixed  with  hot  water  or  any  form  of  soup,  milk,  chocolate,  grog,  or 
punch.  In  process  of  drying,  which  occupies  from  five  to  twenty- 
four  hours,  the  meat  loses  rather  more  than  four  fifths  of  its  weight 
(Huggard). 


ANIMAL   FOODS.  gn 

Dujardin-Beaumetz's  "grog  de  la poudre  dc  viande"  is  prepared  as 
follows :  Take  two  tablespoonfuls  of  meat  powder,  three  dessert- 
spoonfuls of  essence  or  syrup  of  rum  punch,  and  add  milk  enough  to 
make  quite  fluid.  In  this  way  he  claims  that  the  equivalent  of  three 
and  a  half  pounds  of  meat  may  be  given  daily. 

Debove,  Dujardin-Beaumetz,  and  Peiper  strongly  recommend 
powdered  meat  for  forced  alimentation  (see  Suralimentation  in 
Phthisis)  to  replace  feeding  by  the  stomach  tube. 

Beef  blood. — Dried  beef  blood,  powdered,  has  been  recommended 
by  Regnard  and  others  for  use  by  addition  to  soups  and  various 
forms  of  foods. 

The  taste  and  odour  of  dried  blood  is  disagreeable,  and  the  idea 
of  eating  it  in  any  form  is*  repugnant  to  most  persons. 

It  has  also  been  used  for  rectal  injection,  but  I  have  always  ob- 
served it  to  cake  inside  the  bowel,  and  there  is  very  little  evidence 
that  it  is  absorbed  at  all. 

Meat  lozenges  are  prepared  by  Mason  as  a  convenient  and  port- 
able form  of  condensed  nutrition.     Soup  lozenges  are  also  made. 
«       Beef  peptonoids  are  prepared  in   powdered  form  by  several  manu- 
facturers ;  one  variety  contains  predigested  and  sterilised  beef,  milk, 
and  gluten. 

Rudisch's  beef  peptone  (or  sarco-peptones)  is  a  dark-brown,  semi- 
solid paste,  havmg  a  strong  meaty  odour  and  flavour.  One  pound 
of  this  preparation  represents  eight  pounds  of  fresh  lean  beef.  In 
addition  to  the  extractive  materials  which  are  obtainable  in  ordinary 
beef  tea,  it  contains  predigested  proteids  in  a  form  suited  for  prompt 
absorption.  It  may  be  eaten  spread  upon  crackers  or  toast,  or  it 
may  be  dissolved  in  chocolate  or  almost  any  suitable  fluid,  either 
hot  or  cold.  It  is  given  in  doses  varying  from  half  a  teaspoon- 
ful  or  less  for  young  children,  up  to  a  teaspoonful  or  tablespoonful 
for  adults.  If  its  flavour  when  dissolved  in  water  alone  is  disagree- 
able or  becomes  tiresome,  it  may  be  altered  by  giving  it  ice  cold,  or 
by  the  addition  of  salt,  celery  salt,  pepper,  or  Worcestershire  sauce, 
and  for  children  it  may  be  sweetened  with  sugar.  It  is  often  added 
to  milk,  sherry,  eggnog,  gluten,  and  farinaceous  gruels  of  oatmeal, 
rice,  or  arrowroot,  or  it  may  be  used  to  re-enforce  soups,  broths,  and 
jellies. 

The  Maltine  Company  furnish  a  similar  preparation  which  con- 
tains 70  per  cent  of  albuminous  material  with  phosphates,  fat,  and 
carbohydrates. 

The  South  American  beef  extract  is  a  new  predigested  preparation 
which,  by  the  analysis  of  Kemmerich  (Zeit.  fiir  physiolog.  Chemie, 
xviii,  1894),  contains,  with  other  proteid  matter,  a  large  proportion — 
over  27  per  cent — of  albumoses  and  peptones,  ready  for  immediate 
absorption. 


lOo  FOODS  AND  FOOD  PREPARATIONS. 

Somatose  is  a  new  granular  predigested  meat  powder  which,  ac- 
cording to  analysis  reported  by  Hildebrandt  at  a  medical  association 
meeting  at  Elberfeldt  in  1894,  contains  90  per  cent  of  albumoses, 
(deutero-  and  hetero-albumose),  and  is  free  from  peptones.  It  is  of  a 
yellowish  colour,  amorphous,  finely  granular,  having  but  faint  taste 
and  odour.  Dissolved  in  water,  it  forms  a  clear,  light  yellow  or 
brownish  solution,  almost  tasteless.  It  is  not  precipitated  by  heat 
or  by  strong  acids.  The  latter,  in  fact,  redissolve  a  precipitate 
which  is  formed  by  very  weak  acids.  It  is  claimed  for  it  that  it  is 
eight  times  as  nutritious  as  meat,  but  estimates  of  this  kind  applied 
to  artificial  foods  are  always  fallacious.  Of  course  for  an  invalid 
who  cannot  digest  any  meat  such  preparations  are  indefinitely 
"  stronger,"  but  for  those  who  can  assimilate  meat  they  are  much 
weaker. 

Somatose  can  be  injected  without  local  irritation.  It  may  be 
given  as  fine  powder  with  bread  and  butter  or  spread  upon  toast.  It 
is  also  administered  like  similar  preparations  in  milk,  mucilage,  soup, 
cocoa,  or  coffee.  When  mixed  with  such  substances  it  should  be  first 
stirred  into  a  thin  paste  with  an  equal  volume  of  the  fluid  and  then- 
added  to  the  remainder. 

It  is  well  tolerated  by  irritable  stomachs  and  is  speedily  absorbed, 
and  it  possesses  the  advantage  of  having  a  less  disagreeable  taste 
than  many  preparations  of  meat. 

Fluid  Meat  Preparations. — Beef  juke  contains  serum,  lymph, 
and  blood.  It  is  prepared  as  follows:  A  tender  juicy  beefsteak  is 
broiled  for  several  minutes  over  a  quick  fire  so  as  to  coagulate  the 
outside  and  retain  the  juice  well  within.  It  is  then  cut  into  small 
pieces  an  inch  or  two  in  diameter  and  squeezed  in  a  common  lemon 
squeezer  or,  better,  in  a  meat  press,  which  is  sold  in  hardware  shops 
for  this  special  purpose. 

The  juice  is  salted,  and  for  adults  a  little  pepper  may  be  added. 
It  is  best  served  warm,  but  if  preferred  it  may  be  eaten  frozen.  This 
preparation  is  quite  nutritious,  although  less  so  than  scraped  beef. 

When  beef  is  chopped  and  squeezed  under  great  pressure,  juice  is 
obtained  from  it  in  the  proportion  of  two  hundred  and  thirty  grammes 
per  one  thousand  of  meat,  but  only  about  6  per  cent  is  albumin 
(Bauer). 

Fresh  beef  juice  is  serviceable  for  feeding  in  many  cases  of  severe 
gastric  disturbance  with  vomiting  and  pain  ;  also  in  typhoid  fever, 
and  for  feedmg  infants  at  the  end  of  the  first  and  in  the  second  year. 
From  one  to  three  tablespoonfuls  may  be  given  at  once,  and  it. forms 
a  good  introduction  for  the  stomach  to  solid  food.  It  is  usually 
much  to  be  preferred  to  any  of  the  foregoing  extracts  and  other 
preparations.  If  desired,  it  may  be  pancreatinised  like  milk  (see 
Pancreatinised  Milk,  p.  68). 


ANIMAL   FOODS. 


lOI 


Beef  Tea. — The  nutritive  strength  of  beef  tea  has  formed  a  sub- 
ject for  much  discussion.  The  assertion  is  often  made  that  it  is  a 
comparatively  useless  preparation,  and  it  is  said  that  a  pint  of  it  con- 
tains scarcely  a  quarter  of  an  ounce  of  anything. 

Hassell  estimates  that  fourteen  pounds  and  a  half  of  beef  would' 
be  required  to  make  enough  tea  to  counterbalance  the  daily  nitroge- 
nous waste  of  one  man. 

If  rightly  made,  however,  it  may  be  nutritious,  although  the  quan- 
tity of  albuminous  material  which  can  be  dissolved  in  it  at  any  time 
is  much  less  than  that  which  exists  in  a  similar  volume  of  milk  or  in 
an  egg.  The  preparation  of  beef  tea  should  be  conducted  as  follows : 
Tender  lean  raw  beef  is  chopped  into  small  pieces  about  a  quarter  of 
an  inch  in  diameter  and  macerated  in  cold  water  for  five  or  six  hours. 
The  water  is  to  be  added  in  the  proportion  of  a  pint  to  a  pound  of 
lean  beef;  ten  drops  of  hydrochloric  acid  are  then  added,  and  the 
solution  is  gradually  heated  up  to  i6o°  F.,  but  not  more,  for  from 
fifteen  to  thirty  minutes.  This  is  best  accomplished  by  placing  the 
vessel  in  a  larger  outer  vessel  of  boiling  water.  The  water  of  the 
outer  vessel  communicates  its  heat  to  the  inner  one,  but  the  contents 
of  the  latter  does  not  boil  because  the  evaporation  from  its  surface 
prevents  its  temperature  from  rising  to  that  of  the  outside  water, 
which  is  nearer  the  fire.  Various  forms  of  water  baths,  which  the 
French  call  "  bain  marie  "  or  milk  scalders,  are  sold  which  are  con- 
veniently adapted  for  the  process  of  making  beef  tea. 

The  prolonged  soaking  of  meat  in  cold  water  dissolves  its  mineral 
ingredients — chiefly  chlorides  and  sulphates  of  potassium,  and  also 
extractives,  principally  creatin  and  creatinin  and  some  lactic  acid 
derived  from  the  muscle  fibres.  There  may  also  be  a  little  albumin 
present,  but  the  albumin  of  meat  or  muscle,  although  soluble  in 
simple  aqueous  solutions,  practically  does  not  diffuse  out  readily 
into  the  water,  but  the  addition  of  hydrochloric  acid  converts  the 
myosin  into  an  acid  albumin  called  syntonin,  which  passes  much 
more  completely  into  the  acidulated  water. 

In  making  beef  tea,  more  or  less  fat  is  apt  to  be  derived  from  the 
meat  which  floats  upon  the  surface  and  presents  a  very  unappetising 
appearance.  This  should  always  be  skimmed  or  strained,  and  if  it 
collects  on  cooling,  the  operation  can  be  repeated.  A  crust  of  bread 
dipped  beneath  the  surface  will  often  remove  the  supernatant  layer 
of  fat.  The  materials  which  are  present  in  beef  tea  prepared  in  this 
manner  are  not  very  nutritious,  but  they  are  mildly  stimulating  to 
the  mucous  membrane  of  the  stomach  and  to  the  nervous  system, 
and  it  is  probable  that  they  are  for  the  most  part  absorbed  directly 
from  the  gastric  mucous  membrane  without  passing  beyond  into  the 
intestine. 

It  is  always  desirable  to  give  special  attention  to  the  proper  fla- 


I02  FOODS   AND   FOOD   PREPARATIONS. 

vouring  of  food  for  fever  patients.  In  cases  where  a  fluid  diet  is 
necessitated  for  many  days  in  succession,  much  depends  upon  the 
willingness  of  the  patient  to  take  the  food  offered  him,  and  a  dread 
of  too  frequently  recurring  intervals  of  feeding  and  the  positive  dis- 
like which  the  monotonous  taste  of  certain  meat  preparations  gives, 
react  unfavourably  upon  the  digestion.  It  is  advisable  always  to 
consult  the  individual  taste  of  patients  in  this  regard,  and  when  they 
positively  assert  that  they  cannot  take  beef  tea  or  bouillon  or  meat 
.e.Ktracts  in  any  form,  their  opposition  may  be  often  overcome  by 
addmg  the  expressed  juice  of  some  fresh  vegetables  of  which  they 
are  fond.  Carrots,  turnips,  celery,  parsnips,  and  endives  may  be 
boiled  alone  or  with  an  aromatic  herb,  such  as  parsley  or  green  mint, 
and  afterwards  chopped  fine  and  their  juice  expressed  by  squeez- 
ing them  in  a  muslin  bag.  Such  juices  added  to  beef  tea  and  broth 
impart  an  altogether  different  flavour,  which  may  be  varied  from  time 
to  time  by  changing  the  vegetables  (Yeo). 

The  total  quantity  of  albuminous  material  which  can  be  obtained 
in  the  manner  above  described  in  a  reasonable  bulk  of  fluid  is  very 
little,  but  in  febrile  conditions  it  is  usually  good  for  the  patient  to 
ingest  abundant  water,  and  there  is  no  objection  to  part  of  the  fluid 
being  taken  in  the  form  of  beef  tea.  On  the  other  hand,  if  patients 
have  absolute  anorexia  they  are  soon  wearied  by  the  effort  of  swal- 
lowing, and  it  is  preferable  to  give  nitrogenous  food  in  some  more 
concentrated  form. 

In  fever,  albuminous  and  gelatinous  solutions  aid  in  maintaining 
strength  and  diminish  the  tendency  to  exhaustion,  and  for  this  pur- 
pose the  chief  value  of  beef  tea  and  beef  essences  is  found  to  ex- 
sist,  rather  than  for  furnishing  additional  substance  to  the  tissues. 

The  objections  to  the  use  of  beef  tea  are  that  its  preparation  re- 
quires time  and  care,  and  the  taste  soon  becomes  monotonous.  It 
may  be  advantageously  given,  however,  with  vegetable  extracts  or 
beaten  eggs,  or  gelatin  may  be  put  in  to  stiffen  the  mass  into  a  jelly, 
which,  when  properly  seasoned,  is  palatable.  It  may  also  be  thick- 
ened with  broken  crackers,  and  with  the  addition  of  a  little  butter, 
pepper,  and  salt,  it  becomes  much  more  nutritious;  or  sago,  arrow- 
root, or  chocolate  may  be  mixed  with  it. 

For  infants  the  tea  may  be  made  weaker  than  for  adults  by  using 
half  a  pound  of  lean  rump  steak  to  the  pint  of  water. 

Bouillon,  or  the  French /<?/ dr«y>«,  is  of  little  more  value  as  an  ali- 
ment or  heat  producer  than  beef  tea  or  extractum  carnis.  It  is  a 
good  vehicle  for  giving  beaten  or  dropped  eggs,  flour,  etc.  It  stim- 
ulates the  nerves,  but  in  a  much  less  degree  than  alcohol.  It  has  the 
advantage  over  the  latter  and  over  condiments  that  it  is  never  poi- 
sonous. A  good  meat  puree  may  be  made  by  adding  a  tablespoon- 
ful  of  scraped  beef  to  three  or  four  tablespoonfuls  of  bouillon,  warm- 


ANIMAL   FOODS. 


103 


ing  over  a  brisk  fire  until  the  meat  turns  of  a  faint  drab  colour,  and 
seasoning  with  pepper  and  salt  or  a  little  butter. 

Beef  broth  is  agreeable  to  invalids,  but  on  the  whole  it  is  less  nu- 
tritive than  that  made  from  chicken,  veal,  or  mutton. 

Ltebig's  extract  of  meat,  or  extractum  carnis,  consists  of  the  fla- 
vouring extractive  matters  such  as  kreatin,  isolin,  decomposable 
ha^matin,  and  salts.  Some  of  these  substances  are  excrementitious, 
and  on  this  account  Masterman  compares  it  to  urine,  although  it 
contains  less  urea. 

A  pound  of  mutton  is  represented  by  two  fifths  of  an  ounce  of 
the  extract.  It  contains  no  albumin  or  fibrin,  and  has  in  all  but  2 
per  cent  of  solids,  hence  its  nutritive  power  is  practically  nil,  but  when 
regarded  as  a  stimulant  and  so  used,  it  removes  fatigue,  strengthens 
the  action  of  the  heart  and  nervous  system,  and  improves  the  func- 
tional activity  of  the  stomach,  and  in  this  manner  aids  the  digestion 
of  foods.  There  is  no  occasion  for  taking  it  in  large  quantities,  and 
when  this  has  been  done,  symptoms  of  slight  ptomaine  poisoning 
have  been  observed,  such  as  heaviness  and  stupor  (Yeo).  The  ex- 
tract has  the  advantage  of  keeping  for  years  without  decomposition, 
and  it  has  been  found  that  sometimes  in  cases  of  shock,  especially 
after  wounds  received  on  the  battlefield,  its  stimulant  action  has 
been  considered  almost  equal  to  that  of  alcohol,  and  bulk  for  bulk, 
it  is  certainly  much  greater. 

Johnson  s  fluid  beef  is  a  digestible  preparation,  somewhat  less  dis- 
agreeable in  taste  than  many  extracts  of  meat. 

Valentine's  meat  juice  is  a  much-used  preparation  which  resembles 
Liebig's  somewhat  in  its  properties. 

Valentine's  meat  juice  is  a  clear  fluid  of  a  deep  claret-colour,  hav- 
ing a  meaty  odour  and  strong  meaty  taste.  It  is  prescribed  in  doses 
of  one  half  to  two  teaspoonfuls,  diluted  in  eight  times  its  bulk  of 
cold  water,  or  it  may  be  mixed  with  cracked  ice.  Its  taste,  which  is 
disagreeable  to  many  patients,  is  easily  disguised  by  the  addition  of 
half  a  tumblerful  of  milk,  or  it  may  be  mixed  with  light,  farinaceous 
gruels  (after  they  have  cooled  to  130°  F.),  or  used  to  re-enforce  soups 
and  broths  or  cod-liver  oil.  Like  Liebig's  extract,  it  may  be  given 
by  the.  rectum.  An  ounce  of  this  preparation  is  said  to  represent 
the  concentrated  pure  juice  of  two  pounds  of  the  best  lean  beef  or 
the  condensed  essence  of  three  fourths  of  a  pint  of  natural  expressed 
beef  juice.  Among  other  ingredients  it  contains  haemoglobin  and 
some  albumin.  It  keeps  well  in  all  climates  when  tightly  corked. 
It  should  not  be  diluted  with  hot  water,  strong  liquors,  or  acid  medi- 
cines, as  these  substances  alter  it  and  lessen  its  value.  It  may  be 
given  in  champagne  and  in  tea  which  is  not  too  hot. 

Bovinine  is  the  concentrated  expressed  juice  of  raw  lean  beef  ob- 
tained without  use  of  heat  or  acid.     It  is  claimed  that  each  ounce 


104 


FOODS   AND   FOOD   PREPARATIONS. 


represents  nearly  one  pound  of  beef,  that  it  contains  26  per  cent 
of  coagulable  albumin,  and  that  it  keeps  well  without  decomposition 
owing  to  the  addition  of  glycerin  and  alcohol.  It  is  said  to  contain 
egg  albumen  also.  It  may  be  given  />er  os  in  doses  of  a  teaspoonful 
or  more,  or  in  ounce  doses  with  pancreatin  for  rectal  injection.  Not 
being  predigested,  it  may  be  pancreatinised  like  milk  just  before  its 
administration  in  cases  where  it  is  desirable  to  give  absolute  rest  to 
an  irritable  or  ulcerated  stomach. 

Bovinine  has  been  used  topically  for  injection  around  indolent 
ulcers  with  the  idea  of  improving  local  nutrition,  but  it  is  doubtful 
whether  this  procedure  is  of  any  value. 

Beef  Peptones. — There  are  innumerable  fluid  preparations  of  pep- 
tonised  beef  which  are  recommended  for  invalid  consumption  ;  but, 
as  a  rule,  they  are  not  so  good  as  those  which  are  freshly  made  by 
the  addition  of  pancreatin  powder,  although  their  use  saves  time  and 
trouble.  They  may  be  sometimes  employed  to  tide  over  an  emer- 
gency after  a  severe  operation  or  collapse  from  hsemorrhage,  un- 
controllable emesis,  etc.  The  use  of  peptones  for  invalid  foods  is 
open  to  the  objection  that  after  a  short  time  they  excite  disgust, 
and  may  cause  vomiting  and  diarrhoea.  The  more  complete  the 
conversion  of  albumin  into  peptone  the  more  bitter  it  becomes. 

Voit,  Politzer,  Gerlach,  and  others  maintain  that  true  peptone 
possesses  little  if  any  nutritive  power,  and  that  the  albumoses  can 
be  directly  absorbed  from  the  alimentary  canal  without  further  fer- 
mentation into  peptones. 

Of  the  numerous  commercial  preparations  sold  under  the  general 
names  of  peptones,  peptonoids,  predigested  meat  extracts,  etc.,  those 
have  proved  the  most  nutritious  which,  in  reality,  contain  the  least 
peptone,  and  the  most  albumose. 

Bread  and  beef  peptone,  or  panopeptone,  is  a  preparation  in  which 
wheat  starch  and  beef  are  both  predigested  and  preserved  in  sound 
sherry.  It  may  be  taken  cold  in  doses  of  one  to  four  teaspoonfuls 
iced,  or  with  carbonic  acid,  water,  or  wines,  but  it  should  not  be 
mixed  with  milk  or  other  foods.  Beef  peptonoids  are  also  mixed 
with  predigested  milk  and  gluten. 

Summary. — Most  of  these  preparations  are  given  in  doses  of 
one  or  two  tablespoonfuls  once  in  four  hours.  Usually  they  are 
tired  of  soon,  and  do  not  support  life  long,  for,  beyond  the  means 
employed  of  condensation  of  food  by  evaporation  of  water  and  com- 
pression, it  is  not  possible  to  "concentrate"  nourishment  very  much. 
Making  food  assimilable  and  more  useful  is  another  matter  from 
concentrating  it  in  the  sense  that  it  can  be  made  to  support  an  able- 
bodied  man  and  supply  him  with  energy  for  a  day's  work,  for  ex- 
ample, of  mountain  climbing. 

Neither  does  such  predigested  aliment  represent  concentration 


ANIMAL   FOODS. 


105 


for  an  invalid  ;  the  bulk  of  food  given  is  certainly  reduced,  and  its 
assimilation  may  be  improved,  but  it  does  not  convey  into  the  body 
any  phenomenal  quantity  of  latent  force  units  or  of  heat  units.  It 
is  important  to  understand  this  fact ;  otherwise  serious  misconcep- 
tions arise  as  to  the  actual  amount  of  nutrition  which  a  patient 
fed  exclusively  on  peptonoids  and  similar  food  preparations  is 
receiving. 

The  following  analyses  illustrate  the  comparative  composition  of 
some  of  the  preceding  preparations  as  given  by  Chester  : 

Composition  of  Meat  Extracts. 
(Albert  H.  Chester.) 


Water. 

Organic 
matter. 

Ash. 

Soluble 
albumin. 

Alcoholic 
extract. 

Liebig's  extract 

18.27 
40.65 
37.00 
41.20 
54-40 

58-48 
39-85 
55-65 
50.40 
31.84 

23.25 
19.50 

7-35 
8.40 

13-75 

0.05 
I. II 
I.IO 
1. 17 
0.44 

44.11 
13-18 
10.13 

15-93 
26.32 

Benger's  extract  of  beef 

Starr's  extract  of  beef 

Tohnston's  fluid  beef 

Valentine's  meat  juice 

Various  Meats. 

Beef  tongue  is  a  tender  form  of  meat,  but  it  contains  rather  too 
much  fat  to  agree  well  with  delicate  stomachs. 

Veal. — Veal,  especially  when  obtained  from  animals  killed  too 
young,  is  apt  to  be  tough,  pale,  dry,  and  indigestible;  but  when  the 
animals  are  slaughtered  at  the  right  age  the  meat  is  sometimes 
tender,  and  is  regarded  by  many  as  nutritious.  It  differs  consider- 
ably from  beef  in  flavour,  and  contains  more  gelatin.  Veal  broth 
is  nutritious,  and  affords  a  wholesome  variety  in  the  dietary  for  the 
sick.  When  too  much  is  given  it  may  excite  diarrhoea.  Veal  is 
much  more  used  for  invalids  in  Germany  than  elsewhere,  although  it 
figures  less  conspicuously  in  hospital  dietaries  there  now  than  for- 
merly. Bauer  declares  it  to  be  more  digestible  than  beef,  but  Pavy 
says,  referring  to  both  veal  and  lamb,  "  they  are  meats  that  it  is 
desirable  to  avoid,  generally  speaking,  in  case  of  dyspepsia,"  and 
this  opinion  is  prevalent  in  America  as  well  as  in  England.  Veal 
contains  more  water  and  less  fat  and  proteid  than  ox  flesh. 

Mutton. — Mutton  is  rated  as  more  digestible  than  beef  by  Eng- 
lish writers  upon  dietetics.  That  can  hardly  be  said  to  be  the  case 
in  this  country,  where  the  quality  of  beef  has  been  so  much  im- 
proved of  late  years,  and  where  average  mutton  is  not  so  tender  as 
in  England.  For  example,  Balfour  writes  in  his  late  work  upon  the 
Senile  Heart  (1894):  "We  also  recommend  meat  with  short  fibre, 
such  as  chicken,  rabbit,  game,  mutton,  or  well-grown  lamb,  in  prefer- 


,06  .       FOODS   AND   FOOD   PREPARATIONS. 

ence  to  such  meats  as  beef,  whose  fibres  are  long  and  tough."  Fat 
mutton  is  richer  in  fat  than  beef,  and  is  certainly  less  digestible  than 
lean  beef. 

Undoubtedly  tough  mutton  is  quite  as  difficult  of  digestion  as 
tough  beef,  and  it  is  harder  to  obtain  it  tender.  Mutton  fat  contains 
a  larger  percentage  of  stearic  acid,  which  makes  it  firmer  and  less 
digestible  than  beef  fat.  Fat  mutton  is  more  apt  to  disagree  with 
those  whose  digestion  is  enfeebled.  When  properly  assimilated  after 
digestion,  mutton  possesses  equal  nutrient  value  with  beef. 

Mutton  should  not  be  eaten  until  the  sheep  is  at  least  three  years 
old,  and  the  best  English  mutton  is  derived  from  animals  which  are 
six  years  of  age.  Mutton  broth  is  wholesome  and  suitable  for  the 
sick.  It  may  be  given  in  typhoid  and  other  fevers.  It  is  somewhat 
constipating. 

Lamb. — Lamb,  when  very  tender  and  of  just  the  right  age,  is 
quite  as  digestible  as  beef  or  mutton,  but  the  flesh  contains  too  large 
a  proportion  of  fat — more  than  is  present  in  veal.  Good  lamb  is  ex- 
pensive, and,  on  account  of  the  uncertainty  of  the  character  of  the 
meat,  it  is  not  usually  to  be  recommended  for  invalids. 

Venison. — Venison  is  a  tender  meat  with  short  fibres,  which  is 
very  digestible  when  obtained  from  young  deer,  but  it  is  regarded  as 
somewhat  stimulatmg  to  the  stomach,  and  it  is  often  eaten  when 
aged  to  a  degree  which,  while  some  think  it  improves  the  flavour, 
unfits  it  for  dyspeptics.  The  meat  corresponds  very  closely  in 
chemical  composition  to  lean  beef. 

Pork  is  a  tender-fibred  meat,  but  it  is  notoriously  indigestible 
on  account  of  the  high  percentage  of  fat  present,  which  may  exceed 
37  per  cent,  or  considerably  more  than  the  quantity  of  its  nitro- 
genous material.  Pork  ribs  may  have  as  much  as  42  per  cent  of  fat. 
The  fat  is  composed  chiefly  of  palmitic  and  oleic  glycerides. 

Ham  and  Bacon. — Bacon  is  much  more  digestible  than  pork, 
and  ham  occupies  an  intermediate  position.  "  On  an  average,  100 
grammes  of  ham  give  30  of  albuminates  and  32  of  fat;  the  salt 
ranges  between  7  and  10  per  cent  "  (Bauer). 

In  Germany,  and  especially  at  Carlsbad  and  other  mineral 
springs,  ham  i,s  much  prescribed  in  invalid  dietaries.  It  is  often 
given  scraped  or  "  rasped."  Bauer  says  (Dietary  of  the  Sick,  p.  91)  : 
*'  The  flesh  of  the  hog  seems  to  be  better  adapted  for  smoking  than 
that  of  other  animals,  and  long  experience  compels  us  to  recognise 
smoked  ham  as  one  of  the  wholesomest  forms  of  meat.  Whether 
boiled  or  eaten  raw,  it  seems  as  a  rule  to  be  more  easily  digested 
by  weak  organs  than  almost  any  other."  An  opposite  view  is  preva- 
lent in  England  and  America,  where  it  is  less  used  for  the  sick.  So 
distinguished  a  dietician  as  Pavy  omits  mention  of  it  in  his  book 
upon  Food  and  Dietetics.     Ham  is  much  more  digestible  when  thor- 


ANIMAL   FOODS. 


107 


oughly  boiled,  cut  thin,  and  eaten  cold.     It  should  not  be  fried  for 
invalids.     Hot  ham  fat  is  very  indigestible. 

If  cut  thin  and  cooked  crisp,  fat  bacon  is  friable  and  easily 
broken  into  small  particles  during  digestion.  It  can  often  be  eaten 
by  dyspeptics,  and  forms  an  excellent  variety  of  fatty  food  for  con- 
sumptives. According  to  Letheby,  prime  bacon  should  not  lose 
over  one  tenth  of  its  weight  by  boiling,  and  ham  should  lose  even 
less. 

Rabbit  has  white  meat,  but  it  is  not  a  proper  invalid  food. 

Fowl. — Chicken  is  among  the  most  digestible  of  meats  for  inva- 
lids, whether  cooked  by  broiling,  roasting  or  boiling.  The  white 
meat  is  more  easily  digested  than  the  dark,  and  a  little  of  the  breast 
of  chicken  may  be  given  to  a  typhoid  convalescent  or  a  patient 
recovering  from  any  severe  illness  before  beef  and  mutton  are 
allowed.  Chicken  broth  is  almost  universally  liked,  and  when 
thickened  with  rice,  and  sometimes  with  an  tgg,  it  forms  a  highly 
desirable  invalid  food. 

Turkey  and  capon  are  somewhat  less  digestible  than  chicken,  the 
meat  being  of  tougher  fibre. 

Young  pigeons  are  quite  digestible,  and  the  breast  of  a  squab 
may  be  given  to  a  convalescent  from  fever  before  other  meat  is 
allowed. 

Tame  ducks  and  geese  are  indigestible  unless  quite  young  and 
tender,  on  account  of  containing  too  much  fat.  Goose  meat  may 
sometimes  hold  over  40  per  cent  of  fat,  with  which  it  is  thoroughly 
infiltrated. 

Game,  such  as  the  flesh  of  partridge,  grouse,  woodcock,  snipe, 
prairie  chicken,  etc.,  is  by  many  persons  preferred  when  it  is  "  high  " 
— that  is,  when  it  has  been  kept  long  enough  for  putrefactive 
changes  to  occur.  These  may  originate  in  the  meat  itself  or  in  the 
viscera  which  have  not  been  removed  and  from  which  the  odour  and 
flavour  of  commencing  putrefaction  are  derived,  and  penetrate  the 
meat.  When  the  meat  itself  is  not  perfectly  fresh  it  may  produce 
violent  gastro-intestinal  disorder,  but  many  persons  with  good 
digestive  organs  are  not  disturbed  by  the  consumption  of  such . 
food  in  moderation,  provided  it  is  well  cooked.  The  process  of 
cooking  disinfects  it  by  heat.  The  fat  of  old  birds  is  apt  to  be  too 
strongly  flavoured,  and  their  meat  is  tough. 

Animal  Viscera. — Animal  viscera  are  eaten  to  some  extent  in 
this  country,  and  some  of  them  are  digestible,  although  none  are 
as  nutritious  as  good  meat,  and  they  contain  but  little  nitrogen. 
With  the  exception  of  sweetbread,  and  in  some  cases  the  thyroid 
gland,  they  should  not  be  given  to  the  sick. 

Sweetbread  is  most  useful  in  the  invalid  dietary.  This  should 
consist  of  the  thymus  gland  of  the  calf,  which  is  tender  and  has  an 


I08  FOODS  AND  FOOD  PREPARATIONS. 

agreeable  flavour ;  but  butchers  substitute  the  pancreas  or  "  stomach 
bread  "  for  it  whenever  they  can,  which  is  larger.  The  latter  can  be 
recognised  by  its  coarser  blood  vessels,  and  it  is  less  digestible  than 
true  sweetbread. 

The  thyroid  gland  has  been  lately  shown  to  possess  remarkable 
power  in  regulating  disordered  nutrition  in  cases  of  myxcedema, 
chronic  skin  diseases,  etc.  It  is  usually  given  as  a  powdered  extract 
in  five-grain  doses,  but  it  is  sometimes  cooked  fresh  and  eaten  as  a 
food. 

TriJ>e,  made  from  the  third  stomach  of  the  cow,  when  tender  and 
well  cooked,  is  easy  to  digest,  although  somewhat  too  fat.  It  con- 
tains about  i6  per  cent  of  fat  and  13  per  cent  of  albummoids — 
rather  more  than  most  viscera. 

The  heart  is  sometimes  eaten,  but  the  meat  is  tough  and  unde- 
sirable. 

Liver  and  kidneys  are  eaten  more  than  any  other  viscera.  If 
cooked  too  long  they  become  very  hard  and  tough.  Calf's  liver  is 
always  better  flavoured  and  more  tender  if  the  animal  has  had  fresh 
milk  for  food  and  not  boiled  skimmed  milk  and  slops.  Tender  liver 
is  more  easily  digested  than  kidney,  and  is  fairly  nutritious.  It 
should  not  be  allowed  to  diabetics.  These  foods  are  apt  to  be  fried 
or  stewed  in  rich  sauces  or  "  devilled,"  all  of  which  are  indigestible 
modes  of  cooking. 

Brains  are  fairly  digestible,  but  not  nutritious;  they  contain  too 
much  fat  and  cholesterin  for  invalids. 

Blood  has  sometimes  been  used  as  a  fluid  food.  At  one  time 
there  was  a  fashion  among  consumptives  of  going  to  the  abattoirs 
to  drink  it  warm,  in  the  belief  that  it  had  somfe  specific  curative 
value  for  tuberculosis.  This,  however,  is  not  the  case,  and  it 
nauseates  most  persons  to  taste  it,  if  not  to  look  at  it. 

Isinglass. — Gelatin. 

Isinglass  is  derived  from  the  membrane  of  the  swimming  blad- 
der of  the  sturgeon,  but  that  of  other  fishes  is  occasionally  used. 
It  is  not  very  soluble  in  the  crude  state,  but  is  hygroscopic  and 
swells  very  much  in  cold  water.  It  dissolves  in  boiling  water,  and 
when  the  water  is  evaporated  again  hardens. 

Gelatin. — Gelatin  is  a  substance  the  potential  energy  of  which 
is  calculated  as  being  even  more  than  that  of  some  fats  and  albu- 
minates, yet  in  the  body  it  is  very  inferior  in  the  production  of 
force.  It  is  obtained  from  bones,  ligaments,  and  other  connective 
tissues. 

It  is  a  curious  and  interesting  property  of  gelatin  that  used 
alone  it  fails  to  have  much  nutritive  power,  but  in  proper  combina- 
tion with  other  foods  it  is  a  useful  aliment.     "By  the  addition  of 


ANIMAL   FOODS. 


109 


gelatin  very  large  quantities  of  albumin  can  be  spared  in  the  body 
or  devoted  to  increase  of  bulk,  just  as  by  the  supply  of  fats  and 
carbohydrates  "  (Bauer). 

Gelatin  itself  takes  no  part  in  repair  and  growth  of  tissues — it 
must  be  regarded  solely  as  an  "  albumin-sparer."  It  cannot,  there- 
fore, replace  albumin,  the  loss  of  which  still  goes  on  to  some  ex- 
tent even  when  gelatin  is  eaten  in  large  quantity.  It  also  slightly 
spares  the  consumption  of  non-nitrogenous  materials.  This  is  a 
question  of  considerable  importance  in  the  feeding  of  invalids,  be- 
cause, while  many  jellies  are  easily  digested  and  are  agreeable  to  the 
palate,  it  is  useless  to  burden  the  stomach  with  them  if  they  do  not 
possess  nutritive  properties  in  proportion  to  other  foods,  and  the 
matter  must  therefore  be  discussed  somewhat  in  detail.  The  "  Bone 
Soup  Commission  "  of  the  French  Academy  of  Sciences  was  consti- 
tuted to  determine  the  nutritive  value  of  prolonged  boiling  of  bones 
in  order  to  obtain,  if  possible,  an  inexpensive  form  of  aliment  for 
hospital  patients.  The  commission  made  elaborate  researches,  the 
result  of  which  showed  that  animals  which  were  fed  exclusively  upon 
gelatin  rapidly  deteriorated  in  strength  and  weight,  and  finally  suc- 
cumbed to  starvation.  Subsequent  experiments  upon  gelatin  have 
been  conducted  by  many  physiologists  with  these  conclusions  :  i. 
Gelatin  is  innocuous,  and  its  exclusive  use  will  not  support  life.  2. 
Mixed  with  other  foods,  it  promotes  nutrition  and  is  easily  digested 
and  absorbed.  3.  To  some  extent  it  saves  waste  of  albuminous 
tissues. 

Since  bones  consist  of  nearly  two  thirds  of  their  weight  of  gela- 
tin, the  latter  may  be  advantageously  used  as  an  inexpensive 
means  for  furnishing  variety  in  the  diet  by  addition  to  meat  broths 
and  jellies,  pea  and  bean  soups,  etc.  M.  Edwards  says  that  the 
proper  proportion  for  such  mixtures  should  be  at  least  one  fourth 
of  meat  soup  to  three  fourths  of  gelatin  soup.  The  bones  them- 
selves may  be  broken  and  made  to  yield  fat  and  gelatin  for  soup 
"stock."  The  amount  of  nourishment  which  they  afford  is  ex- 
tremely little,  and  they  are  mainly  of  service  for  economic  reasons 
to  save  waste. 

Edible  birds'  nests  are  not  true  gelatin,  but  a  Chinese  food 
product  allied  to  mucin. 

Gelatinous  substance  may  be  obtained  from  boiling  for  several 
consecutive  hours  such  material  as  calves'  feet,  sheep's  trotters,  ox 
tails,  etc.,  and  after  clarifying,  straining,  and  concentrating  very 
palatable  jellies  may  be  made,  to  which  chicken  or  mutton  is  added 
for  invalid  use. 

Calfs-foot  jelly  and  calf s-head  jelly,  if  not  made  too  rich  by  added 
ingredients,  makes  a  suitable  invalid  dish,  especially  when  flavoured 
with  sherry  or  Rhine  wine.     Ox-tail  soup  is  too  rich  for  the  sick. 


no  FOODS  AND  FOOD  PREPARATIONS. 

Pure  white  gelatin  is  insipid,  and  is  almost  impossible  to  eat  in 
considerable  quantity  unless  it  is  well  seasoned.  If  free  from  all 
gluey  taste  and  odour,  and  prepared  with  coffee  or  lemon  juice,  or 
other  fruit  flavours,  it  makes  an  easily  digested  invalid  food.  Or  it 
may  be  combined  with  eggs  or  milk  as  blancmange,  or  with  soup. 
The  addition  of  meat  extracts  to  it  improves  the  taste,  and  the  ad- 
mixture of  wine,  like  good  sherry,  alters  the  taste  rather  by  the  in- 
troduction of  its  aromatic  principles  than  by  the  alcohol  itself,  which 
is  largely  evaporated  from  the  jelly. 

"Well-prepared  jellies,  not  containing  too  much  acid  or  pungent 
spices,  are  very  useful  foods  for  invalids,  and  may  be  administered 
with  advantage  in  febrile  states  "  (Bauer). 

Dry  gelatin  contains  17.3  per  cent  of  nitrogen,  which  is  even  a 
larger  proportion  than  is  contained  in  albumin  ;  consequently  urea 
excretion  is  decidedly  increased  by  gelatin  feeding.  Diuresis  is 
also  produced,  and  the  desire  for  liquid  is  intensified,  so  that  a  large 
proportion  of  gelatin  in  the  diet  causes  decided  physiological  effects. 

Fish. 

Fish  vary  both  in  digestibility  and  nutritive  qualities.  The  chief 
differences  are  in  regard  to  coarseness  of  fibre  and  the  quantity  of 
fat  present.  Fish  meat  is  less  stimulating,  sustaining,  and  satisfying 
than  that  of  birds  or  mammals. 

Eels  contain  the  largest  proportion  of  fat,  which  amounts  to  28 
per  cent.  Herring  have  7,  salmon  about  6.5,  while  sole  has  but  0.25 
per  cent  (Konig).     Mackerel,  trout,  and  shad  have  considerable  fat. 

Fish  which,  like  the  salmon,  are  rich  in  flavour  and  in  fat,  while 
they  may  be  very  nutritious,  are  much  less  easy  of  digestion  than  are 
the  simpler  varieties,  such  as  sole  or  flounders  and  codfish.  Dried 
codfish  can  be  eaten  on  long  sea  voyages  day  after  day  without  the 
repulsion  which  is  soon  excited  by  the  continuous  diet  of  the  more 
highly  flavoured  fatty  fish. 

The  flesh  of  many  fish  contains  a  large  percentage  of  water,  be- 
sides gelatin. 

The  following  fish,  in  the  order  named  by  Walker,  have  the  largest 
percentage  of  albuminoids:  Red  snapper,  whitefish,  brook  trout,  sal- 
mon, bluefish,  shad,  eels,  mackerel,  halibut,  haddock,  lake  trout, 
striped  bass,  cod,  flounder. 

All  fish  are  best  in  their  proper  season,  for  out  of  season  they 
deteriorate  from  change  in  food  or  other  causes,  and  are  less  nutri- 
tious, besides  possessing  inferior  flavour,  and  sometimes  disagreeable 
odour.  They  should  be  eaten  as  fresh  as  possible,  for  there  are  few 
alimentary  substances  capable  of  exciting  so  violent  gastro-intestinal 
disturbance  as  decomposing  fish.  The  practice  of  preserving  fish 
frozen  or  packed  in  ice  is  open  to  the  objection  that  the  cold  pre- 


ANIMAL   FOODS.  Ut 

vents  malodours  from  revealing  commencing  putrefaction.  Vivid 
red  gills  and  fulness  and  brightness  of  the  eye  are  a  good  test  of 
freshness. 

It  is  a  popular  fallacy  that  fish  constitute  a  good  "  brain  food  " 
on  account  of  their  containing  a  large  percentage  of  phosphorus,  a 
prominent  ingredient  of  nerve  tissue;  but  in  reality  many  fish  con- 
tain less  of  this  element  than  meat,  and  neither  Eskimos  nor  other 
aboriginal  tribes  who  live  largely  upon  fish  are  noted  for  intellec- 
tuality. 

Some  fish  contain  different  species  of  tapeworm,  but  they  are 
seldom  if  ever  transmitted  to  man. 

Fish  having  white  meat  constitute  an  excellent  food  for  invalid 
diet,  and  when  cooked  by  boiling  or  broiling  (not  frying)  they  may 
be  given  to  convalescents  and  to  those  with  feeble  gastric  powers. 

The  most  digestible  fish  are  fresh  sole,  whiting,  bluefish,  whitefish, 
bass,  red  snapper,  fresh  codfish,  halibut,  shad,  and  smelt.  Pavy  says : 
"  Of  all  fish,  the  whiting  may  be  regarded  as  the  most  delicate, 
tender,  easy  of  digestion,  and  least  likely  to  disagree  with  a  weak 
stomach.  The  haddock  is  somewhat  closely  allied,  but  has  a  firmer 
texture  and  is  inferior  in  flavour  and  digestibility." 

Crimping  is  a  process  sometimes  applied  to  fresh  fish,  like  the  cod, 
by  which  the  firmness  of  the  flesh,  as  well  as  its  flavour,  is  increased. 
As  soon  as  caught,  the  fish  is  incised  transversely  by  numerous  deep 
cuts.  On  being  plunged  into  ice  cold  water,  the  muscle  fibres  con- 
tract firmly  and  so  remain. 

As  a  rule,  dried,  smoked,  or  pickled  fish  should  not  be  given  to 
invalids,  although  thoroughly  boned  and  desiccated  or  "shredded" 
codfish  is  quite  tender.  The  latter  process  is  now  conducted  by  ma- 
chinery, and  thus  prepared  the  fish  requires  less  prolonged  soaking 
and  cooking. 

Fish  roe  is  not  very  nutritious,  and  it  serves  mainly  as  a  relish. 
Shad  roe,  thoroughly  cooked,  is  not  objectionable,  but  sturgeon's  roe 
or  caviare,  which  is  sometimes  used  as  an  "  appetiser,"  is  capable  of 
arresting  digestion,  especially  when  old,  black,  or  rancid.  Caviare 
contains,  according  to  analyses  by  Konig  and  Brimmer,  water,  45.05  ; 
proteids,  31.90;  fat,  14.14;  salts,  8.91  per  cent. 

It  must  not  be  forgotten  that  some  persons  cannot  digest  fish  of 
any  kind,  or  at  most  can  take  but  one  or  two  varieties  without  pro- 
voking an  attack  of  dyspepsia  or  biliousness.  A  few  tropical  fish  are 
poisonous,  and  constitute  the  only  exception  to  the  general  edibility 
of  vertebrate  animals. 

There  are  no  diseases  in  which  a  fish  diet  possesses  specific  value, 
but  often  in  chronic  Bright's  disease,  lithaemia,  gout,  or  other  condi- 
tions in  which  it  is  undesirable  to  give  much  meat,  it  is  very  service- 
able as  a  compromise. 
xo 


112  foods  and  food  preparations. 

Crustaceans. 

Lobsters,  crabs,  and  shrimps,  although  they  constitute  a  whole- 
some food,  when  absolutely  fresh,  for  those  in  health,  should  never 
be  admitted  to  an  invalid  dietary.  They  are  all  scavengers  of  the 
sea,  and  crabs  not  thoroughly  cleaned  or  imperfectly  cooked  may  be 
poisonous  from  contamination  with  putrid  matter,  although  their 
own  flesh  is  good.  Soft-shell  crabs  are  by  no  means  always  "  soft  " 
when  eaten,  and  their  shells  furnish  a  large  bulk  of  indigestible  res- 
idue, which  may  prove  irritating.  I  recall  one  fatal  case  of  appendi- 
citis caused  by  them. 

Lobsters  are  highly  poisonous  to  some  persons  even  when  fresh, 
and  especially  if  eaten  with  other  food  they  may  excite  nausea, 
vomiting,  and  even  gastro-enteritis.  In  others  they  may  cause  urti- 
caria or  aggravate  existing  skin  eruptions. 

Persons  who  live  at  a  distance  from  the  seashore  are  apt,  in 
making  occasional  visits  to  seaside  resorts,  to  gratify  a  fondness  for 
crustaceans,  fish,  and  shellfish  food  by  an  excessive  indulgence  in 
"  shore  dinners,"  which  result  disastrously  with  stomachs  unaccus- 
tomed to  such  diet ;  but  the  evil  effects  are  fortunately  temporary. 

Shellfish. 

Oysters,  clams,  and  mussels  are  very  nutritious  food,  and  the  for- 
mer at  least,  when  fresh  and  when  eaten  raw  or  properly  cooked, 
are  an  excellent  invalid  aliment.  Oysters  can  often  be  digested 
earlier  than  meat  in  convalescence  from  fevers,  and  in  many  forms 
of  gastric  disorder. 

The  "  soft  part "  of  shell  fish  is  formed  chiefly  by  the  bulkier 
liver,  while  the  tough  harder  portion  is  mainly  the  muscle  which 
attaches  the  animal  to  its  shells.  This  muscle  is  coagulated  and 
rendered  tougher  by  all  forms  of  cooking ;  hence  raw  oysters  are 
more  tender  and  digestible  than  if  stewed  or  broiled.  In  oysters  the 
liver  is  relatively  larger  and  more  nutritious  than  in  clams.  In  rec- 
ommending oysters  to  invalids  it  is  always  best  to  allow  only  the 
soft  parts  to  be  eaten,  and  when  this  rule  is  observed  they  may  be 
cooked  in  a  variety  of  ways — by  stewing,  broiling,  roasting  or  "pan- 
ning," and  steaming — but  they  should  never  be  fried  for  the  sick. 

Both  oysters  and  clams  have  the  advantage  that  they  are  very 
generally  liked,  and  they  make  a  pleasant  variety  of  food  to  relieve 
restricted  diets.  They  impart  an  agreeable  flavour  to  milk  and 
broths.  It  is  customary  to  forbid  their  use  by  diabetics,  on  the 
ground  that  their  livers  contain  glycogen.  Clam  juice  or  plain  clam 
broth  is  almost  specific  for  some  forms  of  vomiting,  especially  sea- 
sickness. It  may  be  tried  in  the  vomiting  of  pregnancy,  and  may  be 
retained  when  beef  juice  and  milk  are  not.     It  is  mildly  stimulating 


VEGETABLE   FOODS. 


113 


to  the  gastric  mucous  membrane,  and  slightly  nutritious  and  laxative. 
It  is  best  obtained  fresh,  but  very  good  canned  or  bottled  prepara- 
tions of  it  are  made  which  keep  pure  indefinitely.  It  may  be  taken 
either  hot  or  cold  with  a  little  Cayenne  pepper  half  an  hour  before  a 
meal.  It  seems  to  have  an  invigorating  effect  upon  the  stomach, 
and  promotes  the  appetite. 

Mussels  are  less  commonly  eaten  in  this  country  than  in  England 
and  some  parts  of  Europe.  They  belong  in  the  same  category  with 
oysters  and  clams,  and  the  remarks  just  made  in  regard  to  the  latter 
apply  to  them  as  well.  There  is  a  form  of  poisoning  by  mussels 
which  is  exceedingly  dangerous  and  sometimes  fatal  (see  Poisoning 
by  Shellfish,  page  353). 

In  some  persons  shellfish,  like  crustaceans,  produce  skin  erup- 
tions, such  as  urticaria,  or  aggravate  existing  eczema. 


IV.    VEGETABLE   FOODS. 

Sugars. 

Sugars  are  crystallisable  carbohydrates  in  which  oxygen  and 
hydrogen  exist  in  proportion  to  form  water.  There  are  many  vari- 
eties, of  which  the  commoner  contained  in  food  or  used  as  an  adjunct 
to  diet  are  cane  sugar,  saccharose  or  sucrose,  grape  sugar  or  glu- 
cose, and  sugar  of  milk  or  lactose.  Inosite,  mannite,  dextrin,  sugar  of 
malt  or  maltose,  honey,  a  sweet  nitrogenous  substance  called  sac- 
charin, and  fruit  sugar  or  levulose  (diabetin)  are  also  used.  Sugar 
may  be  derived  from  the  stems  of  plants,  as  in  the  case  of  the  sugar 
cane,  or  the  palm,  from  tubers  like  the  beet,  from  maple-tree  sap, 
and  from  other  vegetable  growths. 

The  sugars  present  slight  differences  in  their  physical  properties, 
such  as  specific  gravity,  solubility,  and  effect  upon  polarised  light. 
They  also  differ  in  sweetness  of  taste  and  in  digestibility. 

As  foods,  sugars  have  essentially  the  same  uses  as  starches  (see 
Farinaceous  Foods,  p.  119),  for  all  starch  must  be  converted  into 
dextrin  or  sugar  before  it  can  be  assimilated.  For  this  very  reason, 
sugars,  although  they  form  an  excellent  class  of  food,  producing 
force  and  heat  and  fattening  the  body,  are  not  absolutely  necessary 
for  the  maintenance  of  health  if  starches  or  fats  are  eaten. 

They  possess  additional  properties,  in  that  they  have  a  more 
agreeable  flavour  than  starches,  are  more  satisfying  to  the  palate, 
and  they  have  antiseptic  and  preservative  power.  Hence  sugars  and 
syrups  are  extensively  employed  to  preserve  fruits  either  in  solution 
or  in  dried  form,  like  "candied"  cherries,  ginger,  etc. 

When  taken  for  food,  sugar  is  quickly  soluble,  and  on  this  account 
taxes  the  digestive  organs  but  little.     Cane  sugar,  however,  needs  to 


114  FOODS.  AND   FOOD   PREPARATIONS. 

be  converted  into  grape  sugar  before  it  can  be  absorbed  and  assimi- 
lated, and  grape  sugar,  which  needs  no  change,  is  therefore  sometimes 
spoken  of  as  a  predigested  carbohydrate. 

Many  persons  acquire  an  inordinate  fondness  for  sugar,  and  con- 
tinued overindulgence  in  this  food  is  very  sure  to  give  rise  to,  flatu- 
lent dyspepsia,  constipation,  and  disorders  of  assimilation  and  nutri- 
tion.    It  may  even  cause  functional  glycosuria  (see  Diabetes). 

Sugar  is  very  fattening.  In  the  West  Indies  the  negfoes  always 
grow  fat  in  the  sugar  season,  when  they  chew  the  cane  in  the  fields. 

Sugars  are  emphatically  force  producers.  Chauveau  and  Kauf- 
mann  have  demonstrated  that  during  muscular  activity  the  consump- 
tion of  sugar  in  the  body  is  increased  fourfold. 

Harley  found  experimentally  that  the  muscle  energy  producing 
effect  of  sugar  is  so  great  that  two  hundred  grammes  (seven  ounces) 
added  to  a  small  meal  increased  the  total  amount  of  work  done  from 
6  to  30  per  cent,  and  that  when  sugar  was  added  to  a  large  meal  it 
increased  this  total  from  8  to  16  per  cent. 

Sugars  and  the  Urine. — Grape  sugar  and  fruit  sugar  or  levu- 
lose,  when  eaten  in  large  quantity  in  health,  reappear  unaltered  m 
the  urine,  but  the  latter  sugar  in  diabetes  is  said  by  Moritz  to  be 
consumed  within  the  body. 

Saccharose,  eaten  in  excess,  may  reappear  in  the  urine  unaltered, 
or  more  commonly  as  glucose. 

Lactose  is  converted  into  glucose,  and  it  produces  functional  gly- 
cosuria more  easily  than  the  latter  if  eaten  in  bulk. 

Alimentary  glycosuria  usually  ceases  in  a  few  hours  after  discon- 
tinuance of  the  food  which  has  caused  it. 

There  are  some  diseases  in  which  sugar  in  all  forms  should  be 
strictly  avoided,  such  as  flatulent  dyspepsia,  acute  and  chronic  gas- 
tritis, gastric  dilatation,  gout,  rheumatism,  obesity,  and  the  uric- 
acid  diathesis,  and  it  should  be  absolutely  forbidden  in  diabetes. 
Temporary  disturbances  of  digestion  from  eating  too  much  sweet 
food  are  very  common,  and  can  usually  be  rectified  by  simple  reme- 
dies, and  by  withholding  or  diminishing  the  customary  allowance  of 
sugar.  Sugar  eaten  constantly  in  excess  spoils  the  teeth  and  de- 
stroys the  appetite  for  other  food. 

Cane  Sugar. — Cane  sugar,  saccharose,  or  sucrose,  as  used  in 
the  United  States,  is  usually  derived  from  the  clarified  and  crys- 
tallised juices  of  the  sugar  cane,  but  it  is  a'lso  made  from  beet 
root.  The  latter  form  is  somewhat  less  sweet  than  are  the  better 
grades  of  cane  sugar.  Nearly  half  the  world's  commercial  sugar  is 
derived  from  sugar  cane,  and  nearly  half  from  beets.  The  maple 
tree  also  yields  from  2  to  10  per  cent  of  sucrose.  Maple  sugar 
is  eaten  chiefly  as  a  luxury,  on  account  of  its  unique  and  agreeable 
flavour.     It  also  makes  an  excellent  syrup  which  is  in  great  demand. 


VEGETABLE   FOODS. 


IIS 


Cane  sugar  can  be  obtained  from'  the  sugar  pea,  from  the  flower 
buds  of  the  coca  palm,  andfrom  other  substances. 

The  sap  which  is  drawn  from  the  sugar  cane  as  well  as  the  juice 
of  compressed  beet  root  is  not  a  pure  aqueous  solution  of  sugar,  but 
is  mingled  with  other  materials,  chiefly  of  a  mucilaginous  character. 
An  elaborate  process  of  refining  is  applied  in  order  to  produce  the 
commercial  white  sugars  of  various  grades.  The  principal  steps  in 
this  process  areas  follows:  "  i,  Melting  of  the  sugar;  2,  straining 
through  bag  filters ;  3,  filtering  through  charcoal ;  4,  boiling  or 
evaporating  the  decolourised  liquid  in  vacuum  pans;  5,  separation 
of  crystallised  sugar  by  centrifugals  "  (Clark). 

Cane  sugar  was  formerly  sold  more  extensively  than  at  present 
in  the  form  of  coarse  brown  sugar.  This  variety  is  somewhat  im- 
pure, and  on  this  account  has  a  slightly  laxative  action ;  but  the 
great  improvements  made  of  late  years  in  the  processes  of  refining 
sugar,  and  the  extreme  cheapness  of  this  commodity,  place  the 
clarified  forms  of  it  within  the  reach  of  all,  and  even  reduce  to 
a  minimum  the  temptation  for  sophistication  which  was  originally 
much  more  extensively  practised,  especially  in  the  adulteration  of 
confectionery,  with  chalk,  plaster  of  Paris,  etc. 

The  most  highly  refined  cane  sugars  contain  about  0.25  per  cent 
only  of  impurities  and  ash,  but  poorer  grades  hold  i  to  2.3  per  cent, 
with  as  much  water  (Konig).  Cane  sugar  is  about  two  and  a  half 
times  sweeter  than  glucose.  "  Grocer'^  itch  "  is  a  form  of  irritation 
of  the  skin  of  the  hands  sometimes  acquired  from  contact  with  moist 
brown  sugar,  adulterated  with  dirt  or  sand  and  mites. 

Caramel. — By  the  application  of  heat,  at  400°  F.,  refined  cane 
sugar  is  melted,  browned,  and  converted  into  a  non-crystallisable 
fluid  substance  called  caramel,  having  a  slightly  bitter  but  agreea- 
ble taste.  Comparatively  insipid  farinaceous  food,  such  as  corn- 
starch and  farina,  may  be  flavoured  with  it  for  invalid  diet.  Burned 
flour  may  be  used  in  the  same  manner,  but  its  flavour  is  less  agreea- 
ble.    Caramel  is  also  useful  for  flavouring  milk,  custards,  etc. 

Sugar  differs  from  starch  by  containing  another  molecule  of 
water,  or  the  elements  which  form  it.  Starch,  which  forms  fully 
three  fourths  by  weight  of  the  solid  ingredients  of  wheat  flour,  is 
altered  into  sugar  by  heating  with  a  little  sulphuric  acid,  or  even 
by  prolonged  heating  alone  or  "  torrification."  The  latter  pro- 
cess converts  it  into  dextrin,  sometimes  called  **  British  gum,"  on 
account  of  its  substitution  in  commerce  for  gum  arable.  With  pro- 
longed heat  there  is  a  further  change  in  the  starch,  which  becomes 
of  a  brownish  and  finally  black  hue,  passing  through  a  stage  analo- 
gous to  the  formation  of  caramel  from  sugar,  and  with  extreme  heat 
forming  a  residue  of  black  carbon,  all  the  water  having  been  driven 
off.     A   hard,   dried,  thoroughly  browned   bread  crust   or  toast    is 


I  1 5  FOODS   AND   FOOD   PREPARATIONS. 

therefore  similar  to  caramel,  and  every  one  is  familiar  with  its  gain  in 
flavour. 

Sugar  candy  is  made  by  extremely  slow  crystallisation. 

Sorghum  is  a  variety  of  grass  or  cane  from  which  sugar  can  be 
extracted,  but  in  this  country  it  is  used  more  for  the  manufacture  of 
molasses. 

Molasses  and  Treacle. — Molasses  and  treacle  are  products  that 
are  incidentally  formed  in  the  process  of  crystallising  and  purifying 
cane  sugar.  Treacle  is  the  waste  drained  from  moulds  used  in  the 
refining  process,  and  it  contains,  besides  sugar,  acids,  extractives, 
salts,  and  more  or  less  dirt.  Like  cane  sugar,  molasses  constitutes  a 
very  desirable  food,  and  is  highly  nutritious.  Its  use,  both  for  cook- 
ing and  to  add  to  farinaceous  food  and  enhance  its  flavour,  is  too 
well  known  to  require  description.  Molasses,  according  to  Konig, 
contains  acetic  and  formic  acids,  which  impart  their  reaction  to  it. 

Both  treacle  and  molasses,  owing  to  impurities,  are  somewhat 
laxative,  and  the  effect,  as  an  aperient,  of  plain  gingerbread  made 
with  good  brown  molasses  is  due  to  this  property.  For  young  chil- 
dren from  six  to  ten  years  of  age  molasses  sometimes  operates  very 
well  in  keeping  the  bowels  open. 

Plain  molasses  candy  is  a  wholesome  form  in  which  to  give  sugar 
to  growing  <:hildren,  if  they  are  not  allowed  to  eat  too  much  and 
spoil  their  appetite  for  other  foods.  Walker  says  that  "  good  candy 
is  good  food."  Candies  are  apt  to  be  made  too  rich  with  butter,  choco- 
late, and  other  ingredients  when  they  disagree. 

Molasses,  like  syrup,  is  a  good  preservative.  It  has  been  used  to 
preserve  potatoes  in  layers. 

Glucose. — Grape  sugar  is  present  in  almost  all  fruits,  in  the 
sweeter  varieties  of  which  it  exists  in  large  quantity.  In  peaches, 
pineapples,  and  strawberries  it  is  found  with  cane  sugar,  and  in 
grapes,  cherries,  and  honey  it  occurs  in  connection  with  other  varie- 
ties of  sugars.  In  dried  fruits,  such  as  raisins  or  figs,  glucose  is 
present  in  a  gummy  form.  It  is  commonly  manufactured  from 
starch. 

Although  prepared  for  immediate  absorption  from  the  stomach 
and  intestine  and  assimilation,  glucose  is  of  little  service  for  fla- 
vouring other  articles  of  food,  for  when  so  used  it  is  apt  to  produce 
flatulent  dyspepsia  with  acid  eructations.  Moreover,  it  has  less 
strength  of  sweetness  than  cane  sugar,  and,  as  it  is  more  difficult 
to  crystallise,  it  is  much  less  convenient  and  desirable  for  gen- 
eral use. 

Sucrose  and  maltose  can  only  be  absorbed  by  alteration  into  glucose. 
If  glucose  be  eaten  as  a  food,  in  form  of  candy  or  otherwise,  it  over- 
loads the  system  by  being  too  promptly  absorbed.  Malt  extracts, 
syrups,  and  preserves  adulterated  with  glucose  easily  ferment,  for 


VEGETABLE   FOODS. 


117 


nothing  ferments  more  promptly  than  such  combinations  with  the 
bacteria  present  in  the  stomach. 

Lactose. — Lactose,  or  sugar  of  milk,  is  taken  as  a  food  in  some 
quantity  with  ordinary  milk,  and  forms  a  very  important  ingredient 
of  the  diet  of  the  growing  infant,  who  is  unable  to  digest  much 
starch  during  the  first  year  of  life,  and  yet  requires  an  easily 
assimilable  form  of  carbohydrate.  Cow's  as  compared  with  human 
milk  is  deficient  in  lactose,  and  the  latter  should  therefore  be  added 
in  proper  proportion  to  the  milk  of  bottle-fed  infants  (see  Milk  Com- 
position, p.  44).  It  might  be  used  for  sweetening  various  articles  of 
food,  but  it  possesses  no  advantages  over  ordinary  cane  sugar,  and 
is  m  fact  more  expensive  and  less  sweet. 

Mannite. — Mannite  is  obtained  from  the  sweet  juice  of  the  stems 
of  the  ash  tree.  It  is  also  contained  in  beet  roots  and  some  other 
vegetables.  Like  sucrose,  it  crystallises,  and  is  white  and  free  from 
odour.  It  does  not  ferment  with  yeast.  It  is  laxative,  and  it  may  be 
used  in  diabetes,  for  it  is  not  secreted  in  the  urine  as  glucose. 

Levulose. — Fruit  sugar,  or  levulose,  is  now  sold  under  the  name 
of  diabetin,  in  crystalline  form,  for  use  in  diabetes,  on  the  ground 
that  it  is  not  known  to  reappear  in  the  urine.  It  can  be  taken  freely 
and  in  considerable  quantity  without  disordering  digestion,  as  sac- 
charin often  does  after  continued  use.  Diabetin  is  sweeter  than  cane 
sugar,  and  has  a  somewhat  fruity  taste. 

Honey. — Honey  is  a  form  of  sugar  prepared  from  the  nectar  of 
various  flowering  plants  gathered  by  bees,  and  stored  by  them  in 
cells.  It  is  really  a  vegetable  product,  although  manufactured  by  an 
insect.  In  addition  to  sugar,  it  holds  several  other  ingredients,  prin- 
cipally wax,  gum,  pigment,  and  odorous  materials.  The  sugar  exists 
in  two  forms — crystallisable  and  non-crystallisable.  The  former  is 
somewhat  similar  to  glucose. 

Honey  contains,  according  to  Konig:  Water,  16.13;  ^r^i^  sugar, 
78.74;  cane  sugar,  2.69 ;  nitrogenous  matter,  1.29;  ash,  0.12  per  cent, 
besides  traces  of  other  ingredients. 

Honey  was  more  in  demand  for  sweetening  before  the  discovery 
of  a  method  of  making  sugar  from  the  sugar  cane.  It  is  a  whole- 
some food,  and  is  fattening  when  eaten  with  bread.  In  some  coun- 
tries— as,  for  example,  in  the  Black  Forest  of  Baden — the  peasants 
consume  it  as  a  staple  article  of  diet.  Artificial  honey-combs  are 
now  made  from  paraffin,  stamped  into  cells  to  imitate  the  original, 
which  enable  the  bees  to  devote  more  energy  to  the  manufacture  of 
honey  and  bestow  less  on  the  combs. 

Saccharin. — Saccharin  is  a  crystallisable  organic  acid  substance, 
containing,  in  addition  to  the  elements  carbon,  hydrogen,  and  oxygen, 
a  little  sulphur  and  nitrogen.  It  was  introduced  a  few  years  ago  as 
a  substitute  for  sugar,  and  it  is  especially  useful  in  cases  of  obesity, 


Il8  FOODS   AND   FOOD   PREPARATIONS. 

rheumatism,  gout,  and  diabetes,  when  the  withdrawal  of  sugar  is 
followed  by  intense  craving  for  it,  or  a  refusal  to  eat  those  foods 
which  are  customarily  flavoured  with  it.  It  is  antiseptic,  and  has  the 
property  of  acidifying  the  urine,  being  eliminated  unaltered  by  the 
kidneys,  hence  it  can  be  used  medicinally  in  cases  of  pyelitis  or 
cystitis.  It  may  be  given  for  months  at  a  time  without  danger,  if 
the  quantity  prescribed  does  not  exceed  more  than  two  or  three 
grains,  three  times  a  day.  More  than  this  dose  may  cause  gastric 
derangement.  It  may  be  added  to  food  in  cooking,  or  a  one-half 
grain  tablet  may  be  used  to  sweeten  a  cup  of  coffee. 

Cereals  and  other  Starchy  Foods. 

Starchy  Foods  in  General. — The  cereals  in  commonest  use  as 
food  products  are  wheat,  corn,  rice,  rye,  barley,  oats,  buckwheat. 
From  these  are  manufactured  a  variety  of  flours  and  meals. 

About  30  per  cent  of  all  cereals  produced  in  the  world  are  grown 
in  the  United  States,  and  at  least  one  fourth  of  the  total  wheat  pro- 
duction is  from  this  country  ;  on  the  other  hand,  98  per  cent  of  the 
rye  and  75  per  cent  of  the  barley  and  oats  are  grown  in  Europe. 
The  United  States  produces  about  75  per  cent  of  the  corn  of  the 
world.  These  estimates  give  a  general  idea  of  the  relative  use  of 
these  cereals,  and  illustrate  the  great  preponderance  of  wheat  bread 
and  corn  meal  and  other  preparations  of  corn  eaten  in  the  United 
States. 

Besides  the  cereals  and  vegetables  which,  like  the  potato,  are 
composed  chiefly  of  starch,  there  is  a  large  miscellaneous  group  of 
starchy  foods  used  as  flours,  which  are  therefore  conveniently  con- 
sidered with  the  cereals.  Such  are  arrowroot,  tapioca,  cassava,  sago, 
and  peas.  Peanuts,  chestnuts,  and  plantains  are  also  sometimes  used 
to  furnish  flour. 

Starch  is  the  term  applied  to  the  fecula  or  granular  material 
found  in  fruits,  roots,  and  tubers  and  in  the  cellular  tissue  of  plants. 
The  structure  and  form  of  the  starch  granules  vary,  and  those  from 
different  plants  may  be  distinguished  by  microscopic  examination. 

Patients,  as  a  rule,  are  ignorant  as  to  the  nature  and  limitations 
of  "  starchy  foods,"  and  their  conception  of  them  is  based  upon  such 
foods  as  resemble  powdered  laundry  starch  in  appearance,  like  ar- 
rowroot, cornstarch,  etc.  After  being  told  to  eat  no  starchy  foods, 
they  not  infrequently  will  say  they  suppose  that  potatoes  are  not 
starchy.  The  expression  at  best  is  not  an  accurate  one;  for  many 
starch-holding  foods  contain  a  large  proportion  of  other  ingredients, 
especially  proteids,  as  will  be  seen  from  the  following  table  furnished 
by  Riibner : 


PLATE  III. 


«f 


S; 


•• 


RYE 


OATS 


•4 


CORN 


STARCH    GRANULES,    MAGNIFIED. 

{Prmn  Bulletin  Mo.  IS,  Divimm  of  ChemiMry,  United  HUUen  Agrimltuml  Bureau). 


DRAWN   KV   (;F.<p.   MARX. 


VEGETABLE 

FOODS. 

119 

ONE    HUNDRED    PARTS   OF 
CONTAIN — 

DRY   MEAL 

Albumin. 

Starch. 

Wheat 

16.52 
11.92 
17.70 
13-65 

7.40 

6.8—10.5 

56.25 
60.91 

38.31 

77-74 
86.21 

Rye 

Barley 

M  aize 

1\  ice 

Buckwheat 

65.05 

Farinaceous  foods  are  composed  of  flour  of  different  kinds,  and 
constitute  a  subdivision  of  starchy  foods.  The  different  starchy  and 
farinaceous  foods  are  derived  from  a  variety  of  plant  structures,  in- 
cluding roots,  tubers,  bulbs,  stems,  pith,  flowers,  seeds,  fleshy  fruits, 
etc.  Some,  like  the  banana  and  certain  vegetables,  are  eaten  raw, 
but  the  majority  require  cooking,  and  the  starches  derived  from 
grain-bearing  plants  of  the  grass  tribe  or  cerealia  usually  must  be 
prepared  by  grinding  and  milling  before  cooking. 

The  following  table  by  Prof.  Atwater  will  be  found  useful  in  giv- 
mg  at  a  glance  the  average  percentage  of  starch  contained  in  the 
commonest  vegetable  foods: 

Atwater  s  Table  of  the  Percentage  of  Starch  in  Vegetable  Foods. 


Wheat  bread 55.5 

Wheat  flour 75-6 

Graham  flour 71.8 

Rye  flour 78.7 

Buckwheat  flour 77-6 

Beans 57-4 

Oatmeal 68 .  i 

Cornmeal 71.0 

Rice 79-4 


Potatoes 21.3 

Sweet  potatoes 21 . 1 

Turnips 6.9 

Carrots 10.  i 

Cabbage 6.2 

Melons 2.5 

Apples 14 . 3 

Pears 16.3 

Bananas 23.3 


In  round  numbers  it  may  be  stated  that  starch  composes  one  fifth 
of  potatoes,  one  half  of  peas,  beans,  wheat,  rye,  and  oats  (their  flours 
contain  more),  and  three  fourths  of  rice  and  Indian  corn. 

In  addition  to  the  cooking  which  the  cerealia  require,  they  are 
often  predigested  by  diastase  for  invalid  use.  Strong  heat  converts 
starch  to  dextrin ;  but  diastase,  like  the  natural  digestive  ferments, 
can  convert  it  into  maltose,  and  as  such  it  is  fitted  for  absorption. 

Bread  Making. — It  has  been  well  said  that  the  quality  of  the 
bread  used  by  the  inhabitants  of  any  country  is  a  fair  measure  of 
their  civilisation.  Flour  is  prepared  from  various  grains  by  crushing 
and  grinding  processes.  The  grains  consist  of  (i)  an  outer  layer, 
the  husk  or  skin,  which  is  woody,  fibrous,  and  indigestible,  and  which 
in  the  milling  process  is  separated  into  "bran";  (2)  the  kernel 
within  the  husk,  which  is  composed  of  gluten,  fats,  and  salts  ;  (3)  the 
starch. 


120 


FOODS  AND  FOOD  PREPARATIONS. 


To  appreciate  the  important  details  of  bread  making,  it  will  be 
necessary  to  first  review  the  structure  and  composition  of  the  grain 
from  which  the  bread  is  derived. 

Structure  of  the  Wheat  Kernel. 
— The  wheat  kernel  is  subdivided  into 
four  layers.  The  first  or  outermost  layer 
(Fig.  I,  ZT)  consists  of  two  or  three  strata 
of  elongated  cells  the  long  diameters  of 
which  correspond  with  the  long  axis  of 
the  grain.  From  these  cells  slender  fila- 
ments or  tapering  hair-like  processes  pro- 
ject outward.  The  cell  margins  are  ir- 
regular in  outline,  and  appear  somewhat 
beaded. 

Immediately  beneath  the  outer  hairy 
layer  lies  the  second  layer  (Fig.  i,  F), 
consisting  of  more  or  less  quadrangular 
cells,  with  rounded  angles,  which  are  more 
uniform  in  size  than  the  others,  and  grow 
at  right  angles  to  them.  The  third  layer 
(Fig.  I,  K)  consists  of  a  delicate,  trans- 
parent membrane-like  structure.  The 
fourth  or  internal  layer  (Fig.  i,  S)  is  com- 
posed of  large,  almost  rectangular  cells 
arranged  in  one  or  two  strata,  and  which  contain  a  dark  granular 
material  which  may  be  easily  separated  from  the  cell  walls. 

The  grains  of  other  cereals  conform  in  a  general  way  to  the 
structure  of  the  wheat  grain,  although  they  differ  in  the  thickness  of 
the  several  layers,  the  number 

of  their  strata,  and  the  size  of  ^^  c     ^ 

the  individual  cells. 

Bran. — Bran  (Fig.  2,  a) 
contains  carbohydrate  mate- 
rial which  is  but  little  if  any 
digested  in  the  human  ali- 
mentary canal,  although  the 
lower  animals  derive  abundant 
nutrition  from  it.  The  nutri- 
tive salts  of  wheat  are  chiefly 
contained  in  the  bran  ;  and  for 
this  reason,  if  bread  consti- 
tutes the  principal  food  for  a  time,  it  is  best  to  eat  that  which 
contains  some  bran.  But  if  too  much  is  consumed  it  hastens  peri- 
stalsis, and  nutrition  suffers  because  the  food  is  hurried  out  of  the 
alimentary  canal    before   absorption    is  complete.     When    bread    is 


Fig.  I. — Section  through  wheat 
kernel  (from  Rupp).  //,  hair- 
like processes  ;  F,  K,  second 
and  third  layers ;  6',  fourth 
internal  rectangular  cell  lay- 
er ;  a,  b,  c,  d,  successive 
layers  represented  as  partial- 
ly stripped  off. 


a 


Fig.  2.  —  Microscopic  characters  of  wheat 
(+  200)  (from  Landois  and  Stirling),  a,  cells 
of  the  bran  ;  b,  cells  of  thin  cuticle ;  c,  glutin 
cells  ;  d,  starch  cells. 


PLATE  IV 


Maize  Starch        x  145 


Wheat  Starch       x  i4s 
( fVow  liulletin  No.  IS,  Divution  of  ChemiMry,  United  SUden  A(fri(mUur<U  Burexm). 


riTd    BV  (  I.IFFiirili  KKHAKIIHIIN. 


VEGETABLE   FOODS.  12  I 

eaten  with  other  food  containing  nitrogen  and  salts,  white  bread  is 
preferable. 

Gluten. — Gluten  is  separated  in  the  process  of  making  starch 
from  wheat  and  other  grains.  It  is  a  valuable  nitrogenous  food  prod- 
uct, consisting  of  (a)  gluten  fibrin,  soluble  in  alcohol ;  (d)  gluten 
casein,  insoluble  in  alcohol  and  ether;  (r)  mucidin  ;  and  (d)  glutin 
(Fig.  2,  c),  a  sulphur-bearing  constituent.  The  greater  part  of  the 
gluten  is  held  in  the  central  four  fifths  of  the  gram. 

Composition  of  Bread. — Bread  is  really  a  mixed  food,  in  that 
it  contains  so  many  classes  of  ingredients — fat,  proteid,  salts,  sugar, 
and  starch — and  this  is  probably  the  explanation  of  the  fact  that  its 
daily  use  never  cloys  the  appetite.  Although  it  contains  some  fat, 
it  has  not  enough  for  a  perfect  food,  and  hence  the  almost  universal 
custom  of  using  butter  with  it.  Moreover,  it  forms  a  convenient 
vehicle  for  taking  fat  in  this  manner,  and  the  butter  aids  in  the 
mastication  and  deglutition  of  the  bread. 

A  bread  roll  which  weighs  50  grammes  contains,  on  the  average, 
albumin,  4.8;  fat,  0.5;  and  carbohydrates,  30  grammes  (Reuk),  the 
remainder  being  largely  water,  with  a  trace  of  salts. 

According  to  Wilson,  good  wheaten  flour  well  baked  should  yield 
136  pounds  of  bread  per  100  pounds  of  flour. 

Bread  Baking. — Bread  is  made  from  a  mixture  of  the  flour  of 
any  cereal  with  water,  which  is  added  in  definite  proportion,  consti- 
tuting a  dough  which  is  made  uniform  by  kneading  either  by  hand 
or  by  machinery.  A  small  quantity  of  the  ferment  yeast  is  also 
worked  uniformly  into  the  dough  and  the  mass  is  left  to  stand  for  a 
number  of  hours,  during  which  fermentation  progresses,  producing 
from  the  starch,  alcohol,  carbonic  acid,  and  water.  The  best  tem- 
perature at  which  this  leavening  proceeds  is  from  100°  to  110°  F. 
After  remaining  for  some  hours  at  a  uniform  temperature,  the  bread 
is  baked  in  a  hot  oven  the  temperature  of  which  is  sufficient  to  kill 
the  yeast  germs  and  check  further  fermentation. 

Of  all  the  cooking  processes  now  in  use  by  civilised  man,  the 
baking  of  bread  is,  perhaps,  the  most  important.  The  object  of 
cooking  flour  in  this  manner  is  to  make  it  light  and  porous,  so  that 
the  digestive  fluids  may  be  easily  incorporated  with  it.  Flour  eaten 
alone  forms  a  glutinous  or  sticky  mass  which  is  quite  indigestible 
and  difficult  to  swallow,  besides  being  comparatively  tasteless. 
There  are  many  variations  in  the  process  of  bread-making,  but  all 
are  based  upon  the  same  principle — the  development  of  carbonic-acid 
gas  throughout  the  mass  of  dough,  which  bubbles  up  and  causes  it 
to  "  rise  "  or  forces  it  apart. 

Development  of  Carbonic-acid  Gas. — Carbonic-acid  gas  may 
be  generated  or  introduced  in  four  ways:  I.  Indirectly  by  natural 
fermentation  excited  by  the  addition  of  the  yeast  fungus,  Torula  or 


122  FOODS   AND   FOOD    PREPARATIONS. 

Saccharomycetes  cerevisice.  II.  By  the  use  of  "leaven,"  a  name  given 
to  old  dough  in  which  fermentation  has  already  occurred.  III.  By 
the  addition  of  baking  powders.     IV.  Directly  by  "aeration  " 

I  and  II.  Bread  made  by  Yeast  or  Leaven. — When  bread  is  made  by 
yeast  or  leaven  the  process,  which  may  be  divided  into  three  stages, 
is  as  follows : 

(i)  The  wheat  or  other  flour,  finely  ground,  is  mixed  into  a  thick 
paste  with  water,  which  may  be  either  warm  or  cold,  and  to  which 
the  ferment,  together  with  a  little  salt,  is  added;  the  mass  is  thick- 
ened with  flour  to  form  a  dough,  and  the  dough  is  well  worked  by 
hand  or  kneaded  so  that  its  several  ingredients  may  become  most 
thoroughly  incorporated.  If  this  is  not  done  properly  the  bread  is 
lumpy  or  of  uneven  porosity.  The  entire  mass  may  be  prepared  at 
once,  or  a  small  part  of  the  flour  is  first  allowed  to  ferment  for  a 
short  time,  and  then  is  kneaded  into  the  remainder. 

(2)  The  dough  is  ne.Kt  set  aside  for  some  hours  in  a  warm  place 
to  rise.  This  process  consists  of  a  fermentation  which  is  produced 
in  the  flour  by  the  action  of  the  yeast,  resulting  in  the  freeing  of 
carbon  dioxide  and  water.  The  accumulating  carbonic-acid  gas  en- 
deavours to  escape  in  bubbles,  which  become  entangled  in  the  more  or 
less  tenacious  gluten  of  the  flour.  Upon  the  size  and  number  of 
these  bubbles  depends  the  porosity  of  the  bread,  and  this  in  turn  is 
modified  somewhat  by  the  kind  of  flour  used,  the  quantity  of  the  fer- 
ment, and  the  rapidity  with  which  the  development  of  carbonic  acid 
is  allowed  to  proceed. 

(3)  The  final  stage  consists  in  the  baking  of  the  dough  after  it 
has  risen.  The  heat  of  the  oven,  by  expanding  the  carbonic-acid 
gas,  makes  the  bread  still  more  porous  and  "sets"^he  walls  of  the 
little  cavities  which  have  formed  so  that  the  loaf  maintains  its  shape. 
The  gas  is  finally  driven  off,  together  with  a  large  quantity,  but  not 
all,  of  the  water.  The  baked  bread  is  therefore  considerably  lighter 
in  weight  than  the  dough,  much  drier,  and  porous. 

The  water  added  to  make  the  dough  escapes  in  part  through 
evaporation,  and  the  external  portion  of  the  bread  becomes  drier  and 
browner  than  the  interior  or  crumb,  and  constitutes  the  crust.  The 
thickness  of  the  crust  will  depend  upon  the  character  of  the  flour 
used,  the  temperature  of  the  oven,  and  the  duration  of  the  process 
of  baking.  Bauer  claims  that  the  crust  contains  less  nitrogenous 
material  than  the  crumb,  but  this  is  contradicted  by  Dujardin-Beau- 
metz,  and  there  is  no  definite  reason  why  it  should. 

With  the  exception  of  these  changes,  bread  has  practically  the 
same  composition  as  its  original  flour. 

Mixing  meal  or  flour  with  fat  tends  to  prevent  the  evaporation 
of  water  from  the  bread. 

The  chief  art  in  baking  bread  consists  in  arresting  the  yeast  fer- 


VEGETABLE   FOODS. 


123 


mentation  of  the  dough  by  the  heat  of  the  oven  (300°  to  400°  F.)  at 
exactly  the  right  period.  If  fermentation  has  not  proceeded  far 
enough  the  bread  is  tough,  or  sodden,  or  lumpy,  whereas  if  it  has 
gone  too  far  it  acquires  a  sour  taste  by  the  development  from  the 
carbohydrates  of  organic  acids,  such  as  acetic,  butyric,  and  lactic, 
which  are  both  unpalatable  and  unwholesome.  Fermentation  pro- 
duced by  the  use  of  leaven  instead  of  yeast  is  much  more  difficult  to 
control,  and  these  acids,  therefore,  are  more  apt  to  be  formed.  The 
bread  made  with  fresh  brewers'  yeast  is  by  many  esteemed  to  have 
the  best  flavour.  The  process  of  bread  baking  also  causes  the 
starch  granules  to  burst,  if  this  has  not  already  occurred  from  ab- 
sorption of  water  in  the  dough,  and  results  in  the  conversion  of 
some  of  the  starch  mto  dextrin,  with  the  further  formation  of  alco- 
hol and  sugar  (glucose). 

Dextrin  is  soluble,  and  has  the  physical  properties  of  a  gum.  It 
is  obtained  by  heating  starch  to  300°  to  400°.  In  steam-cooked  ce- 
reals, also,  the  starch  is  partially  dextrinised. 

III.  Baking  Potvders. — Carbonic-acid  gas  may  be  developed  in 
bread  by  the  action  of  baking  powders.  These  powders  are  very 
extensively  employed,  and  "a  conservative  estimate  of  the  quantity 
of  baking  powder  used  in  the  United  States  each  year  places  the 
figure  considerably  above  50,000,000  pounds  "  (Clark). 

There  has,  however,  been  much  argument  in  regard  to  their 
wholesomeness,  and  elaborate  researches  in  chemistry  and  the  physi- 
ology of  digestion  have  been  conducted  to  determine  whether  or 
not  the  continued  use  of  these  ingredients  in  bread  is  injurious.  The 
so-called  baking  powders  are  manufactured  by  the  combination  of 
many  different  ingredients,  such  as  sodium  carbonate  with  tartaric 
acid,  the  acid  phosphate  of  lime  with  sodium  carbonate  and  potas- 
sium chloride  (Liebig-Horsford),  or  a  combination  may  be  used  of 
ammonium  carbonate  with  hydrochloric  acid.  It  is  claimed  by  the 
advocates  of  the  use  of  baking  powders  that  they  possess  many  ad- 
vantages, such  as  the  fact  that  the  bread  rises  quicker,  and  that  al- 
though fermentation  does  not  occur,  the  bread  is  more  porous,  and 
hence  more  digestible,  and  that  its  taste  is  not  impaired.  On  the 
other  hand,  it  is  argued  that  such  bread  is  practically  less  wholesome, 
and  that  its  continued  use,  from  the  introduction  of  so  many  chem- 
icals, especially  when  ammonium  carbonate  is  employed,  proves  irri- 
tating to  the  stomach  and  may  excite  dyspepsia  and  gastric  catarrh. 
Even  when  not  used  for  the  making  of  bread  these  baking  powders 
are  often  employed  in  the  preparation  of  various  forms  of  cake 
where  lightness  and  quickness  in  making  are  important  features. 

Baking  powder  when  pure  should  consist  only  of  cream  of  tartar 
and  soda,  with  a  little  flour  added,  and  should  be  free  from  alum, 
ammonia,  etc. 


124 


FOODS   AND   FOOD   PREPARATIONS. 


IV.  Aerated  Bread. — The  process  of  aerating  bread  consists  in 
the  forcing  of  carbonic-acid  gas  into  the  dough  under  pressure.  The 
gas  is  generated  by  the  action  of  sulphuric  acid  upon  lime,  and  while 
there  are  several  methods  of  its  use,  in  general,  about  one  cubic  foot 
of  gas  is  applied  to  fourteen  pounds  of  flour,  although  not  over  one 
half  of  this  quantity  remains  in  the  dough.  It  is  claimed  for  this 
process  that  the  bread  is  exceptionally  light,  dry,  and  porous,  that 
there  is  no  danger  of  malfermentation,  with  production  of  acidity, 
and  that  it  sooner  hardens  when  exposed  to  the  air  as  compared  with 
home-made  bread  prepared  with  yeast. 

Aerated  bread  keeps  fresh  longer  than  other  varieties.  It  has  a 
peculiar  taste  which,  however,  is  preferred  by  some  people.  It  is 
claimed  as  a  further  advantage  for  its  manufacture  that  the  bread 
requires  less  kneading  by  the  sometimes  dirty  hands  of  the  baker. 
Some  twenty  or  thirty  varieties  of  germs  are  usually  to  be  found 
beneath  the  finger  nails  of  persons  who  are  ordinarily  cleanly.  If 
special  care  is  not  taken  by  those  who  prepare  bread  it  is  possible 
for  disease  germs,  particularly  those  of  tuberculosis,  to  be  intro- 
duced from  beneath  the  nails  into  the  dough.  It  has  been  claimed 
that  various  infectious  diseases  might  be  transmitted  in  this  manner. 
The  danger,  aside  from  any  aesthetic  consideration,  is,  however,  ex- 
aggerated, as  the  fermentative  processes,  together  with  the  prolonged 
heat  used  in  baking,  are  fatal  to  most  germs  and  spores.  In  aerated 
bread  salt  is  added  as  in  the  other  processes,  with  the  result  of  mak- 
ing the  bread  firmer  and  somewhat  whiter. 

There  are  many  cereals,  such,  for  example,  as  oatmeal  and  the 
coarser  whole  meals  which  are  exceedingly  wholesome  when  cooked 
by  some  methods,  but  which  cannot  be  baked  into  good  bread  be- 
cause of  the  difficulty  of  making  them  porous,  and  their  attempted 
use  in  this  form  usually  results  in  dyspepsia,  with  heartburn  and 
acid  fermentation. 

It  is  pointed  out  by  Sir  Henry  Thompson  that  when  coarse  meal 
is  necessarily  used  for  bread  making,  it,  "being  a  bad  conductor  of 
heat,  will  have  a  hard,  flinty  crust  if  baked  sufficiently  to  cook  the 
interior;  or  it  will  have  a  soft,  dough-like  interior  if  the  baking  is 
checked  when  the  crust  is  properly  done."  For  this  reason  he  ad- 
vises baking  the  flour  in  the  form  of  flat  cakes,  which  can  be  uniformly 
•heated  throughout.  Palatable  cakes  can  be  made  in  this  manner  by 
a  mixture  of  wheat  meal  and  Scotch  oatmeal. 

The  addition  of  boiled  rice  flour  in  bread  making  causes  the  bread 
to  become  more  adhesive  and  to  hold  more  water.  Hence  bakers 
sometimes  resort  to  this  means  to  make  their  bread  heavier.  By 
turning  the  fresh  loaf  over  occasionally  as  it  lies  upon  the  shelf  the 
water  is  prevented  from  gravitating  to  the  bottom  and  making  it 
sodden.     While  the  primary  object  of  bread  manufacture  is  to  ren- 


VEGETABLE    FOODS. 


125 


der  the  starch  more  soluble,  the  gluten  is  also  easier  digested  after 
fermentation.  Freshly  baked  bread  is  much  less  digestible  than  dry 
bread  for  the  reason  that,  being  more  moist,  it  tends  to  form  a  tena- 
cious bolus  in  the  mouth  which  is  not  readily  mingled  with  the  saliva 
or  other  digestive  secretions.  Dry  bread,  on  the  other  hand,  crum- 
bles into  smaller  particles  which  are  easily  acted  upon  by  the  saliva 
and  pancreatic  juice.  For  the  same  reason,  the  crust  of  bread  is 
more  digestible  than  the  interior  part  of  the  loaf. 

Spoiled  Bread. — Bread  may  be  unfit  for  use  from  being  made  of 
adulterated  or  too  old  flour,  from  turning  sour  from  bad  flour  devel- 
oping excess  of  lactic  acid,  from  becoming  bitter  from  bitter  yeast, 
from  becoming  sodden  from  insufficient  fermentation  or  aeration, 
and  it  may  grow  mouldy  from  exposure  to  air  when  it  is  too  moist. 

"Most  of  the  diseases  of  the  War  of  1812  were  due  to  defective 
food,  and  in  90  per  cent  of  the  cases  the  flour  was  at  fault.  In  the 
War  of  the  Rebellion  similar  reports  were  often  received  "  (Wood- 
ruff). 

VARIETIES   OF   BREAD   STUFFS. 

Bread  of  different  kinds  constitutes  the  staple  starchy  food  for 
Americans,  as  the  potato  does  for  the  Irish  peasantry  and  macaroni 
for  the  Italians. 

The  quantity  of  bread  consumed  varies  somewhat  with  the  ability 
to  obtain  other  articles  of  diet.  For  example,  persons  residing  in 
large  cities  are  apt  to  eat  a  larger  percentage  of  animal  food  and 
less  bread  stuff  than  those  in  the  country.  The  French  labourer  con- 
sumes daily  eight  hundred  grammes  of  bread  in  the  country  against 
five  hundred  in  the  city.  The  most  important  bread  used,  both  from 
the  standpoint  of  its  nutritive  value  and  the  quantity  consumed,  is 
derived  solely  from  wheat  flour ;  but,  for  economical  or  other  reasons, 
this  flour  is  sometimes  advantageously  mixed  with  potatoes  or  bean 
flour.  The  latter,  added  in  the  proportion  of  i  part  to  10  of  wheat, 
gives  a  white  bread  rich  in  nitrogen  and  highly  nutritious.  Corn 
flour  may  be  mixed  in  the  same  proportion. 

Composition  of  Breads  and  Crackers  of  Various  Kinds  (Clark). 


Wheat  bread 

Graham  bread  (wheat) 

Rye  bread   

Boston  crackers 

Soda  crackers 

Pilot  crackers 

Graham  crackers 

Oatmeal  crackers  .... 
Oyster  crackers 


Water. 

Nutrienu. 

'Protein. 

Fats. 

Carbo- 
hydrates. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

3251 

67.5 

8.8 

1.9 

55-8 

34-2 

65.8 

9-5 

1.4 

53-3 

30.0 

70.0 

8.4 

0.5 

59-7 

8.2 

91.8 

10.7 

9.9 

68.8 

8.0 

92.0 

10.3 

9.4 

70.5 

7-9 

92.1 

12.4 

4.4 

74.2 

5.0 

95.0 

9.8 

13-5 

69.7 

4.9 

951 

10.4 

13-7 

69.6 

3.8 

96.2 

II. 3 

4.8 

77.5 

Mineral 
waters. 

Per  cent. 
I.O 
1.6 
1.4 
2.4 
1.8 
I.I 
2.0 
1.4 
2.6 


126  FOODS  AND  FOOD  PREPARATIONS. 

Wheaten  Flour  and  Bread. — In  the  average  composition  of 
wheaten  bread  nitrogen  exists  in  the  proportion  of  i  part  to  21  of 
carbon  (Yeo).  Besides  the  deficiency  in  nitrogen,  there  is  but  a  trace 
of  fat  in  refined  flour,  and  but  little  mineral  matter. 

About  seventy-five  million  barrels  of  flour  are  made  per  year  in 
the  United  States. 

The  best  wheaten  flour  for  wholesome  bread  should  be  of  a  slight 
yellowish-white  tinge,  and  not  too  fine.  The  colour  fades  as  the 
flour  becomes  dry. 

Yellow  flour  is  sweeter  and  more  nutritious  than  white  pastry 
flour,  although  it  makes  a  darker  bread.  The  flour  contains  10  to  11 
per  cent  of  gluten.  Such  flour  when  mixed  with  water  should  form 
a  dough  which  is  both  coherent  and  ductile.  These  properties  are 
due  to  the  gluten  which  it  contains. 

Bread  made  from  good  flour  should  be  porous,  but  not  filled  with 
large  holes,  and  should  have  the  proper  consistence  and  firmness  to 
cut  well  in  thin  slices.  Wheaten  flour  contains  much  less  crude 
gluten  after  thorough  baking,  for  in  the  process  of  strongly  heating 
flours  containing  nitrogenous  material,  the  proteid  as  well  as  the 
starch  becomes  more  soluble  in  water  (Leeds). 

Heavy,  sodden  bread  has  been  insufficiently  fermented. 

Tough,  moist,  imperfectly  baked,  or  hot  bread  is  very  apt  to  ex- 
cite further  fermentation  in  the  stomach,  causing  heartburn  and  other 
symptoms  of  dyspepsia.  The  digestibility  of  such  bread  is  promoted 
by  heating  it  to  drive  off  the  moisture,  and  by  spreading  it  well  with 
butter  to  prevent  it  from  agglutinating  in  the  stomach. 

Water  continues  to  evaporate  from  hot  fresh  bread,  and  such 
bread  should  not  be  covered  tightly,  or  else  it  becomes  sodden. 

Stale  bread  and  dry  toast  are  both  more  digestible  than  fresh 
bread.  In  stale  bread  water  is  evaporated  to  a  great  extent,  so  that 
the  bread  becomes  friable  and  is  more  readily  masticated  and  mingled 
with  digestive  fluids.  The  fact  that  stale  bread  on  being  warmed 
over  becomes  softer  is  accounted  for  on  the  hypothesis  that  in  dry- 
ing the  water  has  not  all  been  evaporated,  but  that  some  of  it  has 
combined  with  the  flour,  forming  a  new  compound,  which  is  disso- 
ciated by  the  further  application  of  heat  (Yeo). 

In  toasting,  the  digestibility  of  bread  is  still  further  promoted  by 
additional  heat  and  the  superficial  layers  are  browned  and  altered  in 
flavour,  acquiring  a  taste  somewhat  similar  to  caramel.  Water  is 
evaporated,  and  a  slice,  if  sufficiently  thin,  bakes  dry  and  crisp 
throughout,  but  if  thick,  the  outer  layers  are  scorched  while  the  mass 
within  may  become  even  softer  than  before  toasting. 

Buttered  dry  toast  is  a  digestible  form  of  invalid  food,  for  if  the 
butter  be  spread  thin  while  the  toast  is  quite  hot  it  penetrates  to  the 
interior,  and  both  fat  droplets  and  starch  crumbs  mutually  protect 


VEGETABLE   FOODS. 


127 


each  other  from  cohering  in  large  masses.  The  butter,  moreover, 
enables  one  to  eat  more  bread  in  this  form.  The  same  is  true  of 
milk  toast,  and  this  furnishes  in  addition  a  means  of  giving  consid- 
erable milk  to  patients  who  are  unwilling  to  drink  it. 

Whole-meal  Bread. — For  some  flours  the  whole  of  the  wheat  is 
used,  the  gluten  nitrates  and  phosphates  being  all  retained.  They 
are  more  delicate  than  oatmeal,  and  more  digestible. 

Wheat  yields  soluble  matter,  such  as  albumin  and  dextrin,  amount- 
ing together  to  about  10  per  cent,  besides  various  salts.  The  in- 
soluble matter  of  the  grain  is  chiefly  starch  and  gluten,  which  con- 
stitute from  72  to  75  per  cent.  Wheaten  bread  contains  about  25 
per  cent  of  carbon  and  1.2  per  cent  of  nitrogen  (or  about  8  per  cent 
of  proteid  material).  The  proportion  which  these  elements  bear  to 
each  other  and  which  is  needed  for  maintenance  of  life  is  carbon 
fifteen  to  nitrogen  one;  hence  it  appears  that  wheaten  bread  alone 
is  not  an  economical  food.  If  man  is  to  live  upon  it  alone  for  any 
length  of  time,  brown  bread  or  Graham  bread  is  better  than  the  vari- 
eties made  from  fine  flour,  from  which  latter  the  nitrogenous  ele- 
ments have  been  largely  removed  by  milling.  A  "  bread-and-water 
diet "  is  proverbially  a  reducing  diet,  and  as  such  it  is  given  to  in- 
subordinate prisoners  (see  Diet  in  Prisons,  page  688),  but  they  can- 
not subsist  upon  it  for  longer  than  two  or  three  weeks  at  most. 

Bread  made  of  whole  meal  is  usually  not  so  light  as  that  made 
with  refined  white  flour.  The  explanation  of  this  is  said  to  be  the 
fact  that  the  silicious  envelope  of  the  grain  contains  a  ferment  resem- 
bling diastase,  which  is  called  cerealin.  While  the  dough  is  rising, 
this  ferment  acts  upon  a  good  portion  of  the  starch,  forming  viscid 
compounds  of  dextrin  and  sugar,  which  by  agglutination  prevent  the 
carbonic-acid  gas  from  puffing  up  the  bread  as  much  as  it  should. 
On  the  other  hand,  too  much  attrition  in  the  mill  ruptures  the  indi- 
vidual starch  granules,  and  without  the  use  of  artificial  baking 
powders  the  bread  will  not  be  light  and  wholesome.  "Seconds"  is  a 
medium  ground  flour  which  makes  a  digestible  bread. 

The  British  Commissioners  of  Prisons  recommended  the  use  of 
whole-meal  bread  for  convicts  at  hard  labour  on  account  of  its  greater 
cheapness  and  nutritive  value,  but  advised  a  modification  in  the  pro- 
cess of  its  manufacture.  The  dough  is  made  of  flour  from  which  the 
sharps,  etc.,  have  been  removed.  The  latter  are  then  added  and 
mixed  thoroughly  with  the  dough  just  before  it  is  ready  for  baking, 
and  it  is  claimed  for  this  process  that  there  is  not  time  for  the  cerea- 
lin to  act,  and  consequently  the  bread  is  much  lighter. 

Pumpernickel  is  a  German  black  bread  made  with  unbolted  meal 
and  sour  dough.     It  is  somewhat  laxative. 

Zwieback  is  a  thoroughly  dry  form  of  bread,  which  is  very  whole- 
some for  invalids.     It  contains  about  16  per  cent  of  solids. 

IX 


128  FOODS  AND  FOOD  PREPARATIONS. 

Graham  bread — so  called  after  Sylvester  Graham,  who  advocated 
its  use — differs  from  white  wheat  bread  by  containing  the  outer  coat- 
ings of  the  wheat  kernel,  called  bran,  which  contain  a  larger  percent- 
age of  albuminous  material  and  of  phosphate.  The  bran,  however, 
while  containing  serviceable  food  products,  is  so  difficult  of  digestion 
that  it  tends  to  irritate  the  mucous  membrane  of  the  intestine  and 
increase  peristaltic  action.  For  this  reason  it  is  more  laxative  than 
white  wheat  bread,  but  also  less  nutritious. 

It  is  a  popular  idea  that  coarse  bread,  black  bread,  whole-meal 
bread,  etc.,  are  more  nutritious  than  the  bread  made  from  refined 
white  wheaten  flour  or  delicate  French  breads.  This  is  not  neces- 
sarily true,  and  much  depends  upon  the  digestive  organs  of  the  in- 
dividual. There  are  peasants  in  Europe  who  can  thrive  upon  the 
coarsest  forms  of  sour,  black  bread,  and  there  are  others  who  can 
use  different  forms  of  fermenting  foods  and  beverages  which  to  those 
unaccustomed  to  them  would  prove  most  injurious.  Such  generali- 
sations cannot  be  made,  for  much  depends  upon  the  condition  of 
life  of  the  individual  and  the  general  habit  of  his  digestive  organs. 
Wheat  bran  contains  about  15  per  cent  of  nitrogenous  material,  3.5 
per  cent  of  fatty  matter,  and  6  to  7  per  cent  of  mineral  substance, 
mainly  phosphates  (Yeo),  all  of  which  materials,  from  a  purely  theo- 
retical standpoint,  should  be  nutritious,  but,  practically,  little  bran 
is  absorbed,  and  it  is  often  irritating,  especially  where  feebleness  of 
the  digestive  organs  exist. 

According  to  Bauer,  "with  wheaten  bread,  rice,  macaroni,  etc., 
the  carbohydrates  are  utilised  to  within  0.8  or  1.6  per  cent,  whereas 
of  black  bread,  potatoes,  and  the  like,  8  to  18  per  cent  of  the  carbo- 
hydrates are  passed  with  the  faeces." 

Decorticated  flour  is  prepared  by  special  methods  of  grinding  with 
the  object  of  removing  two  or  three  of  the  outermost  and  toughest 
coverings  of  the  grain,  but  not  the  inner  envelope.  Yeo  says  of 
bread  made  from  such  flour,  that  while  it  may  be  suitable  "  for 
young  and  growing  persons  with  sound  and  active  digestion,"  it  may 
"  prove  very  indigestible  to  adults  leading  sedentary  lives.  It  makes 
a  bread  which  is  usually  heavier,  moister,  and  of  closer  texture  than 
that  made  from  the  finest  wheat  flour." 

When  digestion  is  not  vigorous,  it  is  better  to  obtain  the  neces- 
sary nitrogenous  material  from  animal  sources.  The  special  uses  of 
coarse  forms  of  bread  will  be  pointed  out  under  the  treatment  of 
constipation. 

The  portion  of  grain  which  is  useless  in  the  diet  of  man  is  whole- 
some for  some  of  the  lower  animals,  who  can  convert  it  into  flesh,  to 
be  eventually  eaten  by  man. 

Gluten  Bread. — Bread  made  from  gluten  flour  is  useful  where 
there  is  a  tendency  to  obesity,  and  is  given  to  diabetics.     It  may  be 


VEGETABLE   FOODS. 


129 


toasted  like  ordinary  bread.  The  best  bread  of  this  kind  is  made  in 
Paris,  but  it  is  very  apt  to  contain  considerable  starch. 

Poluboskos  is  a  gluten  food  which  is  said  by  those  interested  in  its 
manufacture  to  contain  only  0.4  per  cent  of  starch.  The  name  indi- 
cates "  much  nourishment."  It  is  given  to  diabetics  in  doses  of  one 
or  two  teaspoonfuls  in  milk. 

Rye  Bread. — Next  to  wheat,  rye  is  the  most  important  bread- 
making  flour,  although  it  is  less  digestible  for  invalids,  and  it  may  be 
mixed  with  wheat  flour  in  the  proportion  of  two  parts  of  the  former 
to  one  of  the  latter. 

It  has  the  advantage  of  keeping  fresh  longer  than  pure  wheaten 
bread,  and  if  well  made  it  is  wholesome  and  somewhat  more  laxative, 
but  contains  much  less  gluten  than  white  bread  from  wheat.  It 
should  be  baked  in  a  hotter  oven  to  ensure  its  digestibility. 

Biscuits,  Pastry,  Puddings,  etc. — In  addition  to  bread,  an 
almost  innumerable  variety  of  biscuits,  cakes,  pastry,  tarts,  pies,  etc., 
are  prepared  by  the  addition,  in  various  proportions,  of  flour,  milk, 
cream,  butter,  or  other  fat,  sugar,  eggs,  flavouring  extracts,  and 
fruit,  such  as  raisins. 

For  making  pastry,  cake,  and  puddings  of  different  kinds,  the 
finer  grades  of  wheat  flour  are  usually  employed,  although  corn  and 
Indian  meal  are  sometimes  used. 

The  dough  is  raised  in  such  preparations  by  the  help  of  yeast, 
alcohol,  fat,  baking  powders,  or  whipped  white  of  e^%g.  A  hot  fire 
is  used  in  the  cooking,  and  the  puddings  are  either  baked,  boiled,  or 
steamed,  so  that  the  flour  is  altered  by  the  heat  in  much  the  same 
manner  as  in  the  manufacture  of  bread. 

These  foods  vary  so  much  in  richness  and  digestibility  that  it  is 
difficult  to  formulate  any  definite  rules  for  their  use.  In  general, 
they  must  be  avoided  by  all  persons  having  indigestion,  dyspepsia, 
or,  in  fact,  any  severe  illness  ;  but  farinaceous  puddings,  simply  made 
and  thoroughly  cooked,  with  the  addition  of  eggs  and  milk,  play  an 
important  part  in  hospital  dietaries,  and  are  very  good  foods  for 
convalescents. 

Boiled  or  steamed  puddings,  being  unfermented  and  surrounded 
with  abundant  water,  are  very  likely  to  be  sodden  or  stringy,  and 
therefore  wholly  indigestible. 

Pastry,  even  when  light,  is  apt  to  be  too  rich,  and  if  not  well 
cooked  it  is  sodden  or  tough  and  almost  certain  to  disagree,  mainly 
because  of  the  changes  which  the  high  grade  of  heat  produces  in  the 
butter  or  other  fats  used  in  its  preparation. 


I30 


FOODS   AND   FOOD   TREPARATIONS. 


PREPARED   FARINACEOUS   FOODS. 
(Often  called  ^^ Infant  Foods  "  or  "Prepared  Baby  Foods.") 

Prepared  farinaceous  foods  are  made  by  the  following  methods: 
I.  Application  of  heat  alone.  2.  Digestion  with  malt  or  diastase 
combined  with  heat.  3.  After  dextrinisation,  the  food  is  evaporated 
with  milk  or  cream. 

The  prepared  farinaceous  foods  may  be  eaten  alone  or  diluted 
with  water,  but  they  are  usually  given  to  invalids  in  a  cup  of  broth 
or  beef  tea,  which  disguises  their  sweetness.  The  sweeter  varieties 
are  best  combined  with  milk. 

I.  Farinaceous  Foods  prepared  by  Heat  alone. — Flour  ball,  Ridge's 
Food,  Blair's  Wheat  Food,  Schumacher's  Food,  Imperial  Granum^ 
and  Robinson's  Patent  Barley  are  examples  of  this  class. 

Wheat  and  oats  are  sometimes  prepared  by  roasting  (not  steam- 
ing), a  process  which  removes  all  moisture  besides  producing  some 
chemical  changes  in  the  fats  and  starches.  Cereals  treated  in  this 
manner  will  keep  from  moulding  in  any  climate,  and  are  both  diges- 
tible and  nutritious. 

Imperial  Granum  is  a  type  of  a  large  class  of  prepared  foods, 
the  basis  of  which  is  starch,  which  has  been  modified,  it  is  claimed, 
so  as  to  render  it  easily  digestible.  Such  foods  are  often  fed  to 
very  young  infants,  but  no  greater  mistake  can  be  made,  for  their 
digestive  apparatus  is  wholly  unfit  to  deal  with  starch  in  any  form 
The  human  infant  is  designed  to  be  nursed  at  the  breast  for  the 
first  year  of  life,  and  Nature  has  furnished  ample  food  for  it  which 
is  wholly  devoid  of  starch.  The  saliva  and  pancreatic  secretion 
upon  which  the  digestion  of  starches  depends  are  not  fitted  for  this 
work  at  all  during  the  first  eight  or  nine  months  of  life,  and  then 
only  partially,  hence  starchy  foods,  "  farinaceous  baby  foods,"  should 
never  be  given  at  all  before  that  age  as  foods,  and  should  only  be 
used  very  sparingly,  if  at  all,  as  mechanical  diluents  of  milk.  More- 
over, in  such  simple  starchy  foods  as  arrowroot  the  proportion  of 
tissue-building  to  heat-producing  foods  is  one  to  twenty,  whereas  in 
human  milk  it  is  one  to  five  (Starr).  Even  when  the  starch  of  in- 
fant foods  is  rendered  soluble  or  dextrinised  or  converted  into  sugar, 
the  absorption  of  too  much  of  such  material  diverts  energy  which 
can  be  better  employed  in  controlling  metabolism  in  other  ways  or 
removing  waste. 

Granum  is  composed  of  over  three  fourths  starch,  made  into  a 
fine  flour.  One  teaspoonful  of  it  should  go  to  each  three  ounces  of 
water,  in  which  it  is  boiled  for  ten  minutes.  An  equal  quantity  of 
milk  is  then  to  be  added,  and  the  mixture  must  be  again  boiled  for 
five  minutes. 


VEGETABLE   FOODS. 


^3-1 


The  mixture  may  sometimes  be  fed  to  infants  after  the  eighth  or 
ninth  month,  but  only  once  or  twice  in  twenty-four  hours. 

Flour  ball  is  prepared  by  boiling  wheat  flour  tied  in  a  bag,  with 
the  purpose  of  converting  it  into  dextrin,  and  it  is  a  popular  belief 
that  this  conversion  is  almost  if  not  quite  complete;  but  Leeds  has 
shown  by  recent  analyses  that  even  after  seventy-five  hours  of  con- 
tinuous boiling  the  percentage  of  soluble  carbohydrates  is  increased 
by  only  0.05  of  i  per  cent,  whereas  some  of  the  prepared  foods  con- 
tain from  two  to  six  times  as  much  soluble  carbohydrate  as  wheat 
flour. 

Flour  ball  tastes  flat  and  insipid,  owing  to  the  long  boiling  dis- 
solving out  fat,  soluble  albuminoids,  and  salts  (Leeds). 

Starr  gives  the  following  rule  for  the  making  of  flour  ball : 

Tie  one  pound  of  unbolted  wheat  flour  firmly  in  a  pudding  bag 
and  boil  for  ten  hours.  At  the  end  of  this  time  it  will  be  found,  on 
opening  the  bag,  that  the  outer  layer  of  the  ball  is  doughy,  while  the 
interior  is  hard  and  dry,  it  having  been  baked  by  the  long-continued 
heat.  This  hard  mass  may  be  used  for  infant  feeding  in  the  latter 
part  of  the  first  year,  but  it  should  not  be  given  more  than  twice  a 
day.  The  flour  ball  is  grated  fine,  and  it  may  then  be  prepared, 
according  to  Starr's  rule,  as  follows:  "Rub  one  teaspoonful  of  the 
powder  with  a  tablespoonful  of  milk  into  a  smooth  paste,  then  add  a 
second  tablespoonful  of  milk,  constantly  rubbing  until  a  cream-like 
mixture  is  obtained.  Pour  this  into  8  ounces  of  hot  milk,  stirring 
well,  and  it  is  then  .ready  for  use." 

The  flour  ball  thus  prepared  is  quite  digestible,  and  it  prevents 
the  formation  of  large  curds  of  milk.  But  its  usefulness  as  a  means 
of  giving  dextrin  to  invalids  in  cases  of  feeble  gastric  power  is  se- 
riously called  in  question  by  Leeds's  analysis. 

As  a  diluent  of  milk  it  is  much  cheaper  for  the  poor  than  the  pre- 
pared amylaceous  foods  which  are  on  sale. 

2.  Farinaceous  foods  digested  with  malt  or  diastase  with  heat  are 
often  called  "  Liebig's  Foods." 

Liebig's  foods  are  made  of  equal  quantities  of  wheat  flour  and 
barley  malt,  with  bran,  and  i  per  cent  of  bicarbonate  of  potassium. 
These  ingredients  are  mixed  into  a  paste  with  water  and  digested 
for  several  hours  at  fixed  temperatures,  until  the  starch  is  trans- 
formed into  soluble  carbohydrates,  maltose,  and  dextrin.  The  food 
is  strained,  pressed,  and  extracted  with  warm  water,  evaporated, 
dried,  and  pulverised,  when  it  is  ready  for  use. 

Examples  of  Liebig's  type  of  dextrinised  foods  are:  Mellin's  Food, 
Horlick's  Food,  Savory  and  Moore's  Infant  Food. 

According  to  Leeds's  analysis,  the  best  samples  of  Mellin's  and 
Horlick's  foods  contain  no  starch,  but  a  large  percentage  (Mellin's 
68.18  per  cent,  Horlick's  76.83)  of  soluble  carbohydrates,  and  about 


132  FOODS  AND  FOOD  PREPARATIONS. 

lo  per  cent  each  of  albuminoids — if  the  process  is  complete.  Savory 
and  Moore's  food  he  finds  contains  considerable  starch. 

Mellins  Food  consists  of  brown  sweetish  granules,  easily  soluble 
in  both  hot  and  cold  water,  milk,  etc.  It  is  made  of  coarsely  ground 
wheaten  flour  with  the  addition  of  malt  and  potash.  It  is  then 
digested  with  water  at  a  moderate  temperature  to  form  dextrin  and 
sugar.  Afterwards  it  is  strained  through  sieves  and  evaporated  in  a 
vacuum  pan. 

Mellin's  Food  is  often  fed  to  infants,  but  it  contains  too  much 
sugar  without  fat  for  a  wholesome  baby's  food  for  continued  use  in 
quantity.  About  one  teaspoonful  is  dissolved  in  two  ounces  of  water 
and  half  a  pint  of  milk.  It  may  be  resorted  to  temporarily  when 
good  cow's  milk  cannot  be  obtained. 

Benger's  Food  is  a  preparation  of  wheaten  flour  to  which,  after 
cooking,  pancreatic  extract  is  added.  When  mixed  with  warm  milk 
both  milk  and  flour  are  newly  digested.  A  tablespoonful  of  the  food 
is  dissolved  in  two  ounces  of  cold  milk.  Then  half  a  pint  of  boiling 
milk  or  milk  and  water  is  slowly  stirred  in.  Further  pancreatinisa- 
tion  is  then  arrested  by  boiling  for  twenty  to  thirty  minutes.  The 
preparation  has  no  bad  taste  and  is  a  nutritious  and  digestible  food 
in  cases  of  gastric  ulcer,  phthisis,  dyspepsia,  etc. 

3.  Foods  which  are  Dextrinised  and  then  Evaporated  with  Milk  or 
Cream. — These  are  sometimes  called  "  milk  foods."  Such  are  Lac- 
tated  Food,  Malted  Milk,  Loeflund's  Cream  Emulsion,  Nestle's  Food, 
Gerber's  Food. 

The  general  process  by  which  foods  of  this  class  are  made  is  as 
follows : 

Wheaten  or  other  flour  is  first  made  into  dough,  baked,  ground, 
mixed  with  more  or  less  condensed  milk  or  cream,  and  then  dried  at 
a  moderate  temperature.  By  addition  of  malt  or  diastase  the  starch 
is  partially  converted  into  dextrin  and  maltose,  and  the  albuminoids 
are  rendered  slightly  more  soluble,  the  casein  is  dried,  and  the  lact- 
albumin  is  precipitated. 

One  form  of  *'  cereal  milk  "  is  made  from  a  mixture  of  wheat  and 
barley  meal  with  milk. 

It  is  claimed  for  some  of  the  malted  foods  prepared  for  infant 
and  invalid  use  that  the  artificial  digestion  is  not  wholly  completed, 
and  this  is  said  to  be  an  advantage  in  stimulating  the  digestive  or- 
gans. 

Malted  milk  is  a  powdered  sterilised  preparation  of  pure  cow's 
milk  and  extracts  of  malted  barley  and  wheat,  the  starch  of  which 
has  been  converted  into  dextrin.     The  mixture  is  dried  in  vacuo. 

The  casein  of  the  milk  is  predigested  by  a  vegetable  ferment. 
The  preparation  keeps  well  while  hermetically  sealed,  and  when  re- 
quired for  use  for  an  infant,  from  one  to  four  teaspoonfuls  are  dis- 


VEGETABLE   FOODS. 


133 


solved  in  from  eight  tablespoonfuls  to  a  half  pint  of  water.  For 
adults,  two  tablespoonfuls  of  the  powder  in  a  half  pint  of  water  make 
the  strength  of  cow's  milk.  The  idea  upon  which  this  preparation  is 
based  is  to  furnish  a  substitute  for  human  milk  which  will  keep  wf  11, 
which  can  be  quickly  made  ready  for  use,  and  in  which  dextrin  takes 
the  place  of  additional  fat. 

It  resembles  Mellin's  Food  somewhat,  except  that  it  contains 
some,  though  not  enough  fat.  It  is  used  in  about  the  same  propor- 
tion. It  makes  a  better  invalid  food  for  adults  than  for  infants,  and 
1  have  known  patients  with  enteric  fever  and  severe  gastro-intestinal 
disorder  take  it  with  benefit. 

NestU's  Food  is  prepared  in  Switzerland,  at  Vevey,  from  sterilised 
fresh  cow's  milk  to  which  wheaten  bread  crust  is  added  after  dex- 
trinisation  by  additional  heat.  Cane  sugar  is  then  mixed  in,  and  the 
mass  is  finally  dried,  pulverised,  and  hermetically  sealed  in  tin  cans. 

For  use  it  merely  requires  dilution  with  water. 

Carnrick's  Food  is  composed  of  evaporated  or  desiccated  milk 
partly  peptonised  and  thoroughly  sterilised  by  heat,  45  parts;  dextrin 
and  soluble  starch,  45  parts;  milk  sugar,  10  parts. 

Bread  Jelly. — A  bread  jelly  may  be  made  to  add  to  milk  for 
invalids  and  for  use  while  weaning  infants  who  are  old  enough  to 
digest  a  little  starch — i.  e.,  over  one  year  of  age.  The  crumb  of 
stale  bread  is  broken  into  small  fragments  and  covered  with  boiling 
water,  in  which  it  is  allowed  to  soak  until  well  macerated.  The 
water  is  then  strained  oft',  fresh  water  is  added,  and  the  mass  is  boiled 
until  quite  soft.  On  cooling,  a  jelly  forms  which  may  be  mixed  with 
milk  in  any  desired  proportion. 

Farina  is  a  general  name  meaning  flour,  and  is  defined  by  Web- 
ster as  "  the  flour  of  any  species  of  corn  or  starchy  root " ;  but  in 
England  the  term  corn  itself  is  applied  to  wheat,  or  used  as  a  general 
name  for  any  grain  growing  in  ears.  Farina  as  sold  by  grocers  in 
this  country  is  often  made  from  wheat,  but  much  of  the  gluten  and 
bran  has  been  separated,  rendering  it  less  nutritious  than  whole 
wheat.  In  cases  of  diarrhoea  it  is  more  bland  and  less  irritating 
than  whole  wheat. 

The  name  farina  is  also  applied  to  fine  white  potato  starch,  which 
forms  a  jelly  when  cooked,  like  arrowroot. 

Wheatena  is  a  nutritious  food  containing  all  the  wheat  berry  ex- 
cepting the  husk,  and  thereby  differing  from  finer  preparations  in 
which  the  layer  of  gluten  cells  is  removed  with  the  bran.  The  starch 
granules,  moreover,  have  been  ruptured  by  heat.  It  is  commonly 
eaten  as  a  thin  mush  or  porridge. 

Crackers. — Crackers,  the  manufacture  of  which  has  attained 
special  reputation  in  the  United  States,  are  now  made  in  great  varie- 
ties both  as  to  hardness,  digestibility,  and  flavour. 


iM 


FOODS   AND   FOOD    PREPARATIONS. 


All  kinds  of  crackers  enter  more  into  the  dietary  in  America  and 
England  (where  they  are  called  "biscuits")  than  in  any  other  coun- 
try. The  lighter  forms  of  sugar  wafers  are  nutritious  and  very 
easily  digested  by  invalids  having  mild  gastric  disorder,  for  the 
starch  has  been  well  torrefied. 

Generally  speaking,  crackers  are  quite  as  digestible  as  good 
bread,  and  the  simplest  forms,  such  as  water  crackers  or  milk  crack- 
ers, are  made  with  flour  and  water  or  milk,  to  which  a  little  salt  is 
added,  after  which  they  are  baked  in  flat  shapes  so  as  to  become 
hard  and  more  or  less  brittle.  Soda  is  sometimes  added.  If  it  is 
desirable  to  have  them  less  friable,  butter  may  be  added  in  small 
quantity.  The  unleavened  preparations  known  as  "  ship  biscuits," 
"  hard-tack,"  and  "  pilot  biscuits,"  which  form  an  important  article 
of  diet  for  sailors  at  sea,  are  manufactured  upon  these  principles. 

S/ii/>  biscuits  are  so  dry  and  firm  that  they  are  much  less  bulky 
than  bread,  and  it  is  estimated  that  three  fourths  of  a  pound  of  such 
biscuits  is  equivalent  to  one  pound  of  bread  in  actual  nutritive  value 
(Yeo). 

All  biscuits,  if  kept  long  exposed  to  the  air,  become  exceedingly 
dry  and  tasteless,  although  they  do  not  readily  mould.  Owing  to 
their  hardness  and  unpalatableness  when  long  kept,  it  is  found  in- 
expedient to  give  them  to  soldiers  or  sailors  to  the  exclusion  of  fresh 
bread  whenever  the  latter  can  be  obtained.  The  biscuits  known  as 
"  hard-tack  "  are  usually  made  five  inches  square  and  are  perforated 
with  small  holes.  They  have  the  advantage  of  keeping  well  for  a 
very  long  time  and  remaining  edible,  although  they  are  not  very 
palatable  even  when  fresh.  They  are  extremely  tough,  and  require 
soaking  in  milk  or  water  before  they  can  be  eaten. 

Semolino  is  a  name  having  two  applications.  In  France  it  de- 
notes the  hard  central  substance  of  the  wheat  grains  which  are 
retained  in  the  bolting  machine  after  separation  of  the  finer  por- 
tion which  has  passed  through ;  but  in  Italy  the  word  is  used  to 
denote  the  finer  portion  itself,  consisting  of  fine  hard  granules 
rounded  by  grinding.  The  larger  sizes  contain  more  gluten  than 
flour,  and  may  be  used  to  thicken  soups.  The  granules  swell  in 
water.  When  the  grinding  and  sifting  process  is  carried  still 
further  the  starch  granules  are  obtained  in  the  fine  powder  which 
constitutes  flour. 

Semolino  is  used  extensively  in  the  manufacture  of  what  are 
called  "  alimentary  pastes,"  such  as  macaroni. 

Macaroni  is  made  by  mixing  semolino  made  from  hard  flinty 
wheat  into  a  paste  which  is  kneaded  and  put  into  a  cylinder,  the 
bottom  of  which  is  pierced  with  holes.  A  piston  descends  in  the 
cylinder,  and  the  paste  issues  from  the  perforations  in  the  form  of 
long  thin  tubes,  which  are  cooled  by  a  ventilator,  cut  in  lengths,  and 


VEGETABLE   FOODS. 


135 


dried  on  screens.  As  much  as  twenty  million  pounds  of  macaroni 
are  manufactured  annually  in  Lyons  alone.  It  contains  16  to  18 
per  cent  of  gluten,  whereas  bread  holds  10  to  11  per  cent. 

Sir  Henry  Thompson  says,  in  speaking  of  macaroni,  which  is 
rather  a  form  of  gluten  than  of  starch,  that,  "  weight  for  weight,  it 
may  be  regarded  as  not  less  valuable  for  flesh-making  purposes  in 
the  animal  economy  than  beef  or  mutton.  Most  people  can  digest 
it  more  easily  and  rapidly  than  meat;  it  offers,  therefore,  an  admi- 
rable substitute  for  meat,  particularly  for  lunch  or  midday  meals." 

After  thorough  soaking  and  when  well  cOoked  by  boiling  or 
stewing  in  milk  or  stock  it  is  very  nutritious,  and  it  is  often  agree- 
ably combined  with  cheese,  although  this  is  not  advised  for  persons 
with  feeble  digestive  power.  Cooked  alone  with  boiling  water,  maca- 
roni is  by  many  regarded  as  tasteless;  and  as  the  art  of  cooking  it 
properly  is  less  understood  in  this  country  than  in  Italy,  it  is  not  so 
favourite  an  article  of  diet  as  it  might  be. 

The  use  of  Italian  pastes — macaroni,  spaghetti,  and  vermicelli — 
in  this  country  is  extensive,  but  by  no  means  as  much  so  as  their 
intrinsic  value  deserves.  They  are  manufactured  from  flour  from 
which  the  starch  has  been  in  part  removed,  and  hence  contain  a 
relatively  larger  proportion  of  nitrogenous  matter.  While  being  very 
wholesome  they  are  tough,  and  require  prolonged  cooking.  The 
vermicelli  which  is  sold  in  the  form  of  letters,  to  use  in  soups, 
cannot  be  boiled  sufficiently  to  be  thoroughly  digestible  unless  the 
letters  lose  their  shape. 

Buckwheat. — Buckwheat,  or  blackwheat  as  it  is  sometimes 
called,  is  indigenous  to  temperate  climates,  and  in  some  parts  of 
the  world,  notably  in  Russia,  Siberia,  and  Brittany,  it  constitutes  a 
staple  of  diet,  but  in  the  United  States  it  is  the  least  important  of 
the  cereals,  and  is  used  rather  as  a  luxury  for  making  griddle  cakes. 
The  buckwheat  produced  in  the  United  States  is  mainly  raised  in 
New  York,  Pennsylvania,  and  some  of  the  New  England  States. 
Buckwheat  bread  is  nutritious,  but  it  crumbles  and  does  not  keep 
well. 

Soya  bread  is  made  from  an  oily  pea  which  grows  in  China  and 
Japan,  and  is  used  sometimes  by  diabetics,  for  it  contains  over 
one-third  part  of  gluten  and  but  1.17  per  cent  of  glucose. 

Millet  and  sorghum  are  grown  in  the  warmest  parts  of  Asia  and 
Africa,  and  to  some  extent  in  southern  Europe.  In  Russia  millet  is 
sold  as  a  white  meal.  White  sorghum,  which  is  a  grass  or  cane,  is 
converted  into  flour  called  doura,  and  in  Africa,  mingled  with  barley, 
it  is  distilled  into  beer.  A  fine  quality  of  alcohol  may  be  made  from 
it.  In  the  United  States  it  is  mainly  grown  for  molasses  and  sirup; 
sugar  is  also  made  from  it.  Bread  made  from  either  millet  or  sor- 
ghum meal  is  fairly  palatable  and  nutritious  when  warm,  but  when 


Ij^  FOODS   AND   FOOD   PREPARATIONS. 

it  becomes  cold  it  grows  dark  and  crumbles.  The  grains  are  hulled 
like  barley  and  are  ground  into  flour,  which  is  either  eaten  pure  or 
mixed  with  bread.  Millet  is  a  grass  raised  largely  in  India,  China, 
Egypt,  along  the  west  coast  of  Africa,  in  Italy,  Spain,  and  Portugal. 
There  are  many  sub-varieties.  It  contains,  on  an  average,  over  7 
per  cent  of  fat,  nearly  10  per  cent  each  of  proteid  and  dextrin,  60 
per  cent  of  starch,  and  2  of  sugar  (Parkes). 

Rye. — Rye  may  be  said  to  stand  very  close  to  wheat  in  impor- 
tance as  a  food.  In  Europe  it  is  more  in  use  for  bread  making  than 
in  this  country,  where  it  is  mainly  eaten  by  the  Germans.  In  Ger- 
many the  rye  production  is  double  that  of  wheat,  and  in  Russia  it 
is  three  times  greater.  Former  generations  lived  almost  entirely 
upon  rye  in  France,  as  they  did  upon  oats  in  Scotland  and  parts  of 
England,  wheat  being  an  almost  unobtainable  luxury. 

Rye  yields  a  coarser,  darker  bread  than  wheat,  but  is  about 
equally  nutritious,  although  not  always  so  digestible,  and  it  is 
somewhat  laxative.  In  general,  the  statements  made  in  the  preced- 
ing pages  (pp.  119-121)  in  regard  to  bread  making,  etc.,  with  wheaten 
flour,  may  be  applied  to  rye  flour. 

Rye  bread  contains  less  gluten  than  wheaten  bread,  and  it  takes 
less  time  to  raise  and  bake  it,  provided  the  oven  is  very  hot.  If 
properly  made  it  is  easily  assimilated,  and  many  like  its  taste. 

Rye  is  often  combined  with  wheat  in  France,  under  the  name 
of  meteil,  and  in  Spain  and  Greece  a  mixture  of  the  same  name  is 
made  with  barley  instead  of  wheat. 

Corn.T— Maize,  or  Indian  corn,  is  very  extensively  grown  in  tem- 
perate and  warm  climates  all  over  the  world.  It  may  be  dried, 
parched,  and  roasted  whole,  or  ground  into  meal  of  various  degrees 
of  fineness. 

According  to  Clark  (Tenth  United  States  Census  Reports,  volume 
on  Agriculture),  the  average  annual  crop  of  corn  in  the  United 
States  alone  is  over  one  and  a  half  billion  bushels,  and  72,000,000 
cans  of  corn  are  prepared,  the  latter  representing  the  harvest  of 
40,000  acres. 

There  are  some  300  varieties  of  corn,  but  the  common  kinds 
are  known  simply  as  white,  yellow,  and  red. 

The  chief  preparations  of  corn  are  hominy,  samp,  corn  meal, 
cracked  corn,  cerealine,  and  maizena  (a  South  American  corn  meal, 
used  in  the  manufacture  of  a  drink  called  "  chicca  "). 

Aside  from  its  use  as  a  food,  corn  furnishes  alcohol  and  liquor, 
as  well  as  glucose  and  starch. 

Chittenden  and  Osborn  have  made  an  elaborate  research  into 
the  chemical  composition  of  the  "  proteids  of  the  corn  or  maize 
kernel  "  (American  Chemical  Journal,  vol.  xiii,  Nos.  7  and  8,  and 
vol.  xiv,  No.  i).      These  consist  of  "  three  globulins,  one  or  more 


VEGETABLE   FOODS. 


137 


albumins,  and  an  alcohol-soluble  proteid "  called  maize  fibrin  or 
zein. 

Corn  is  a  wholesome  cereal,  for  it  contains  considerable  fat  and 
proteid  as  well  as  starch,  and  it  furnishes  abundant  energy,  produc- 
ing heat.  It  is  very  fattening  for  both  the  lower  animals  and  man. 
In  the  Southern  States  and  in  France  it  is  largely  fed  to  horses. 

As  a  vegetable,  corn  is  less  used  in  Europe  than  in  America, 
perhaps  on  account  of  the  prevalent  Tdea  that  it  is  a  hog's  food, 
although  corn  meal  is  employed  for  baking  into  cakes  and  to  mix 
with  flour  in  bread  making.  Eaten  as  a  vegetable,  unless  very  young 
and  tender,  corn  is  one  of  the  least  digestible  foods,  and  canned  corn 
is  notoriously  so.  This  is  chiefly  on  account  of  the  toughness  of  the 
husk  of  the  kernel,  which  often  is  found  in  the  faeces  practically 
unaltered  by  its  transit  through  the  body.  Hence  it  may  cause 
flatulency,  indigestion,  and  diarrhoea. 

Corn  tneal,  on  the  other  hand,  is  quite  digestible,  and,  like  oat- 
meal, is  somewhat  laxative.  As  compared  with  wheaten  flour,  it 
contains  more  fat,  having  about  9  per  cent,  but  it  is  deficient  in 
salts.     It  makes  a  dry,  friable  bread. 

Samp  is  a  very  digestible  form  of  corn  when  well  boiled. 

When  maize  becomes  mouldy  it  causes  the  disease  known  as 
pellagra  (see  Diet  in  Pellagra). 

Polenta  is  a  maize  meal  extensively  used  in  Italy.  The  finest 
variety  of  corn  meal,  or  rather  of  cornstarch,  is  very  white  and  soft, 
and  consists  almost  wholly  of  starch. 

Indian  corn-starch  contains  53  per  cent  of  starch.  The  best 
grades  are  used  as  a  substitute  for  arrowroot,  and  make  a  wholesome 
invalid  food. 

The  coarser  meal,  called  Indian  meal,  is  yellow  and  granular. 
Corn  is  also  used  for  the  manufacture  of  commercial  starch. 

Mush  is  made  of  well-ground  corn  meal.  The  cereal  is  boiled  in 
salted  water,  and  when  cooked  is  not  pasty,  but  mixes  well  with 
cream,  and  is  very  digestible  and  nutritious. 

Rice. — Although  less  eaten  in  this  country  than  wheat,  corn, 
and  rye,  except  in  the  Southern  States,  rice  constitutes  the  staple 
food  of  a  majority  of  the  world's  inhabitants.  Asia  produces  most 
of  the  rice  consumed,  but  a  little  is  grown  in  Spain,  Italy,  and 
Portugal.  According  to  Clark  (Tenth  United  States  Census  Re- 
port on  Agriculture),  "  in  Asia  a  large  part  of  the  population  con- 
sume two  hundred  and  seventy-five  pounds  per  head  a  year,"  and 
nearly  two  billion  pounds  are  used  per  year  in  Europe,  In  the 
United  States,  where  rice  was  first  introduced  in  1694,  it  is  chiefly 
grown  in  South  Carolina.  There  are  several  hundred  varieties  of 
rice,  the  two  principal  classes  being  the  dry  or  mountain  rice,  and 
the  wet  rice,  which  grows  in  flat  marshland,  periodically  inundated. 


138 


FOODS  AND   FOOD  PREPARATIONS. 


Both  the  Chinese  and  Japanese  make  a  wine  from  rice,  and  a 
vinegar  can  also  be  obtained. 

The  native  Oriental  method  of  treating  rice  is  to  beat  the  ker- 
nels of  grain  out  of  their  husks  in  wooden  mortars,  and  for  European 
markets  they  are  glazed  by  shaking  in  a  sheepskin-lined  drum 
(Clark).  They  are  also  bleached,  and  may  be  broken  after  de- 
cortication and  ground  into  a  flour. 

Rice  contains  more  starch  than  any  other  cereal — from  75  to  85 
per  cent — and  is  an  exceedingly  digestible  form  of  starch  for  in- 
valids when  properly  cooked,  so  that  the  individual  grains  are 
swollen  or  softened.  This  object  is  best  attained  by  the  process 
of  steaming.  The  digestibility  of  plain  boiled  rice  is  improved  by 
eating  it  with  a  little  fresh  butter,  which  coats  the  kernels  and  pre- 
vents their  agglutination  into  a  pasty  mass.  If  the  rice  tastes  in- 
sipid it  may  be  spiced  or  flavoured  with  raisins.  Rice  pudding, 
milk  and  rice,  and  rice  with  beefsteak  juice  constitute  excellent 
foods  for  young,  growing  children,  and  for  use  in  convalescence 
from  typhoid  fever,  diarrhoeas,  and  many  other  diseases.  It  is  also 
advantageous  to  eat  rice  with  fruit,  such  as  apples  or  prunes. 

Rice  should  not  be  depended  upon  without  some  form  of  animal 
food,  for  it  contains  too  little  nitrogen  to  satisfy  to  the  needs  of  the 
system. 

Bread  cannot  be  made  economically  from  rice,  on  account  of  the 
small  amount  of  nitrogen  which  this  cereal  contains,  and  the  con- 
sequent lack  of  stability  in  the  shape  of  the  loaf,  and  unless  wheat 
be  added  in  large  proportions,  such  bread  is  indigestible  and  watery. 

Barley. — Barley  ranks  very  close  to  wheat  in  nutritive  power, 
and  cooked  barley  meal,  like  wheaten  flour,  contains  gum,  albu- 
minoids, starch,  and  dextrin.  As  compared  with  wheat,  barley  con- 
tains more  fat,  salts,  and  indigestible  cellulose,  less  proteid,  and  less 
digestible  carbohydrates. 

The  employment  of  barley  bread  for  food  is  of  very  ancient 
date,  reaching  back  to  the  early  days  of  the  Greeks  and  Hebrews, 
but  with  the  spread  of  the  use  of  potatoes  and  the  cheapening  of 
wheaten  flour,  it  has  fallen  into  comparative  disuse,  and  in  the 
United  States  barley  is  mainly  used  to  thicken  soups  and  in  the 
manufacture  of  beer.  In  some  of  the  Pacific  States  it  is  fed  to 
horses.  Pearl  barley  is  made  by  depriving  barley  corn  of  their 
outer  shells  or  covering,  and  then  subjecting  them  to  rubbing  be- 
tween a  single  millstone  and  a  sheet  of  rasped  iron  or  wire  cloth,  a 
process  which  polishes  the  kernels  and  rounds  them  off. 

Barley  water  makes  an  excellent  diluent  and  demulcent  drink 
for  infants  and  invalids.  For  the  latter  it  may  be  flavoured  with 
lemon  juice.  It  may  be  made  as  follows:  Grind  half  an  ounce  of 
pearl  barley  in  a  coffee  mill,  add  six  ounces  of  water,  boil  twenty 


PLATE  V. 


Rice  Starch        x  150 


Rice  Starch       x  450 
(fVom  Bulletin  No.  13,  Diinnion  of  Chemistry,  (hiUed  fiUUeK  AgricultunU  HureAiu). 


i'llOTO    BY  I  l.irKiiKK  Kl<  HAKIiSON. 


VEGETABLE   FOODS. 


139 


minutes,  add  salt,  and  strain.  It  should  be  made  fresh  daily  and 
kept  in  a  cool  place.  It  is  better  than  oatmeal  water  whenever  the 
bowels  are  loose.  The  latter,  made  in  a  similar  manner,  is  to  be 
preferred  when  constipation  exists. 

Oatmeal. — Oats  contain  considerable  fat,  proteid  salts,  and  indi- 
gestible cellulose,  in  addition  to  a  large  percentage  of  starch.  They 
have  been  eaten  in  Germany  for  over  a  thousand  years,  and  consti- 
tuted the  original  grain  food  for  all  Europe. 

Oatmeal  is  much  less  used  than  other  cereals  for  bread  be- 
cause it  lacks  gluten,  although  it  is  still  so  employed  to  a  limited 
extent  among  the  poorer  classes  in  France.  It  makes  a  dark,  bitter 
bread,  but  forms  a  better  porridge  than  can  be  obtained  from  rice  or 
barley.  The  use  of  oatmeal  porridge  by  all  classes  is  very  exten- 
sive throughout  the  United  States.  This  is  largely  attributable  to 
the  improved  methods  of  its  preparation  by  high  milling,  rolling, 
etc.  Scotch  groats  are  prepared  by  removing  the  outer  husk,  leav- 
ing the  grain  almost  whole.  The  grain  is  then  reground  between 
closer-set  millstones.  It  forms  two  grades  of  meal,  the  coarser  of 
which  is  used  for  porridge  and  the  finer  to  make  bannocks  or  oat- 
meal cakes.  A  good  deal  of  the  oatmeal  sold  in  America  is  identical 
with  Scotch  groats.  True  Scotch  groats  are  heated  by  the  miller 
over  perforated  iron  plates  and  slightly  parched  for  three  or  four 
hours  before  being  ground.  For  those  who  can  digest  oatmeal  well, 
it  ranks  among  the  cheapest  and  most  satisfying  of  foods. 

The  nutritious  value  of  oatmeal  is  great,  but  it  depends  very 
largely  upon  the  skill  with  which  it  is  cooked.  It  is  not  infre- 
quently cooked  in  such  a  manner  that  the  individual  grains  are  left 
whole,  but  in  this  form  the  flavour  is  less  well  developed  than  it  is 
by  prolonged  cooking;  the  oatmeal  granules  are  much  more  diffi- 
cult of  digestion,  and  are  capable  of  exciting  gastro-intestinal 
irritation  in  feeble  persons.  But  for  many  people  oatmeal  thus 
cooked  possesses  a  decided  advantage  from  the  fact  that  it  is  less 
completely  absorbed,  leaving  a  considerable  residue  which  adds  to 
the  bulk  of  fiecal  matter,  excites  peristaltic  action,  and  reduces  the 
liability  to  constipation.  For  most  persons,  however,  and  especially 
for  all  those  with  limited  digestive  power,  oatmeal  should  be  so 
thoroughly  cooked  as  to  acquire  the  consistence  which  enables  it 
to  be  easily  poured,  and  on  cooling  it  should  form  a  tender,  gelat- 
inous mass. 

Oatmeal  is  a  very  hearty  food,  and  those  who  eat  much  of  it 
should  live  a  vigorous  outdoor  life.  If  ill-cooked  and  if  given  to 
very  young  children,  it  occasions  colic,  flatulence,  and  rashes. 

It  is  best  when  of  recent  crop  and  freshly  ground.  If  it  is  kept 
long  it  absorbs  moisture,  and,  losing  its  delicate  flavour,  becomes 
mouldy  and  sour  (Clark). 


140 


FOODS   AND   FOOD   PREPARATIONS. 


The  following  analysis  of  oatmeal  is  given  by  Letheby. 

Nitrogenous  matter 12.6  per  cent. 

Carbohydrates,  starch,  etc 63 . 8    "       " 

Fatty  matter 5.6    "       " 

Mineral  matter 3.0    "       " 

Water 15  o    "      " 

Total 100. o    "       " 

Oatmeal,  like  cornmeal,  has  more  proteid  and  fat  than  the  flours 
and  meals  derived  from  other  cerealia,  and  hence,  like  bread,  it  may 
be  eaten  daily  without  impairing  the  appetite. 

Revalenta,  or  revalenta  arabica,  is  a  farinaceous  food  much  eaten 
in  some  parts  of  Europe,  which  is  a  mixture  of  several  meals,  princi- 
pally ground  peas,  beans,  corn,  and  lentils,  but  barley  and  oatmeal 
may  be  included. 

Arrowroot. — Arrowroot  is  derived  from  the  rhizomata  or  root 
stocks  of  several  kinds  of  tropical  plants  grown  in  both  the  East  and 
West  Indies.  The  roots  are  washed,  reduced  to  a  pulp,  strained, 
dried,  and  pulverised  into  a  very  fine  starchy  flour.  The  best  flour 
is  made  from  the  Maranta  arundmacea.  It  is  obtainable  in  market  in 
the  form  of  a  fine  white  powder,  and  consists  of  exceptionally  pure 
starch,  the  granules  of  which  are  small  and  friable.  It  has  a  very 
bland,  insipid  taste,  and  it  is  as  digestible  or  more  so  when  cooked 
than  any  other  starch  which  is  used  in  making  gruel  or  jellies  for 
invalids.  In  the  form  of  a  jelly  it  keeps  longer  without  souring  than 
do  many  other  forms  of  starchy  food,  such  as  the  potato;  and  in  bad 
cases  of  dyspepsia,  when  much  gastric  irritation  exists,  it  often  con- 
stitutes a  serviceable  article  of  diet.  Arrowroot  is  sometimes  fed  to 
young  infants,  but  it  is  unwholesome  for  them,  and  sours  the  stomach. 

Tous-les-mois. — Tous-les-mois  is  a  starch  derived  from  a  West 
Indian  tuber  by  maceration,  straining,  washing,  and  drying.  It  is 
used  for  the  same  purpose  as  arrowroot.  Its  granules  are  the  larg- 
est of  any  of  the  food  starches,  but  they  are  quite  digestible  and 
nutritious  for  invalids.     They  are  soluble  in  boiling  water. 

Salep. — Salep  is  a  starchy  food  which  is  obtained  from  the  tuber- 
cles of  certain  Oriental  orchids.  It  is  a  mixture  of  starch  and  mu- 
cilage which  makes  a  useful  demulcent  drink. 

Tapioca,  Cassava. — Tapioca  and  cassava  are  made  from  the 
rhizomata  of  the  Manioc  utilissitna  (spelled  also  manihot),  a  common 
plant  in  temperate  and  tropical  regions.  It  is  extensively  grown  in 
South  and  Central  America,  Africa,  and  the  West  Indies.  Manioc 
flour  forms  the  basis  of  food  of  the  natives,  and  when  made  into 
bread  and  cakes  it  replaces  the  wheaten  bread  of  Europe  and  North 
America.  Cassava  contains  a  poisonous  juice  that  must  be  first 
drained  off. 


PLATE  VT. 


## 


\ 


MARUNTA 


i^    # 


SAGO 


PEAS  BEANS 

STARCH  GRANULES,  MAGNIFIED. 

{From  Bulletin  No.  IS,  Division  of  Chmiidry,  JMte(tlSldier:AjricuUund  Bureau). 


DRAWN   BY  IJEO.   MARX. 


VEGETABLE   FOODS. 


141 


Tapioca,  which  is  purified  cassava,  is  made,  like  sago,  by  drying 
on  hot  plates,  the  clarified  starch  being  first  heated  into  a  paste  in 
large  metal  pans.  It  is  an  almost  pure  starch.  The  granules  are 
not  tough,  and  are  very  easily  digested,  so  that  they  form  one  of 
the  most  useful  of  the  amylaceous  foods  for  persons  with  feeble 
digestions.  Tapioca  may  be  eaten  alone  in  the  form  of  puddings 
with  cream  or  flavoured  with  lemon  juice,  wine,  nutmeg  or  other 
spice  or  aromatic,  or  may  be  used  to  thicken  broths  or  soups.  "  Pearl 
tapioca  "  is  a  spurious  article  made  from  potato  starch. 

Sag^O. — Sago  is  an  easily  digestible  form  of  starch  derived  from 
the  pith  found  in  the  stem  of  different  varieties  of  palm  from 
Sumatra,  Java,  and  Borneo.  It  is  commonly  sold  in  market  in  a 
granular  form,  and  is  known  as  "pearl  sago."  This  is  prepared  by 
adding  water  to  sago  flour  so  as  to  form  a  paste  which  is  run  through 
sieves  to  granulate  it.  The  spherical  form  of  the  granules  is  ac- 
quired by  allowing  them  to  fall  into  a  shallow  iron  pan  held  over  a 
fire.  Sago  is  made  with  milk,  cream,  and  eggs  into  nutritious  pud- 
dings, and  it  may  be  used  to  thicken  broths  and  soups  of  various 
kinds.  It  has  an  agreeable  flavour,  somewhat  more  delicate  than 
tapioca,  and  is  an  invaluable  adjunct  to  the  invalid  dietary. 

Iceland  moss  {Cetraria)  is  a  lichen  sometimes  employed  as  foo^ 
after  purifying  it  by  washing.  It  contains  at  first  various  bitter' 
principles,  which  must  be  eliminated.  It  can  be  made  into  bread  or 
used  as  an  ingredient  of  blancmange,  etc.  It  has  been  recom- 
mended by  Senator  and  others  for  use  by  diabetics  to  replace  ordi- 
nary bread,  and  it  makes  a  convenient  vehicle  for  the  administration 
of  fats,  such  as  bone  marrow  (Walker).  It  also  forms  a  good  demul- 
cent decoction. 

Several  forms  of  seaweeds  are  used  as  food  by  the  Japanese, 
Siamese,  and  Polynesians.  • 

Starchy  Foods  for  Children. 

The  best  cereals  and  other  starches  for  children  are  rice,  hominy, 
Indian  meal,  barley,  oatmeal,  cracked  wheat  or  wheaten  grits,  farina, 
cornstarch,  and  sago. 

When  the  cereal  grains  are  used  instead  of  flour,  they  should  be 
soaked  in  cold  water  for  five  or  six  hours  and  then  cooked  for  two 
or  three  hours  in  a  double  boiler.  If  fed  to  infants  less  than  two 
years  of  age  or  to  children  with  any  gastro-intestinal  disorder,  they 
must  be  thoroughly  strained.  They  should  be  salted  and  served 
with  cream,  but  without  much  sugar. 

The  steamed  preparations  of  oats,  wheat,  etc.,  which  are  sold  in 
market,  may  be  boiled  one  hour,  and  otherwise  treated  as  the  grains. 

Bread  and  crackers  may  be  allowed  to  infants  after  the  first 
eighteen  months,  but  only  with  their  meals. 


142 


FOODS   AND   FOOD   PREPARATIONS. 


The  bread  should  always  be  porous,  well  baked,  and  stale.  It 
may  be  toasted,  or  given  dry  in  milk,  or  moderately  buttered.  Zwie- 
back and  plain  rusk  is  also  good  food  for  young  children. 

Crackers  are  made  in  great  variety  for  children.  They  should 
not  be  too  dry  or  hard.  They  may  be  eaten  in  milk  or  with  beef 
juice,  or  separately,  with  meals  only.  The  best  are  those  made  of 
wheaten  or  Graham  flour,  oatmeal,  or  gluten.  The  latter  are  the 
least  palatable. 

A  large  variety  of  prepared  cereal  foods  are  sold  and  recom- 
mended especially  for  children's  use.  These  foods  have  been  con- 
verted by  heat  or  malt  to  dextrin  and  glucose  or  maltose,  but  they 
often  contain  a  deficiency  of  flesh  formers,  and  should  never  be  long 
relied  upon  for  feeding  young  infants  to  the  exclusion  of  more  natu- 
ral food  (see  Prepared  Farinaceous  Foods). 

Diastase,   Malt  Extracts,   etc. 

Diastase  is  a  vegetable  ferment  which  has  the  property  of  con- 
verting starchy  foods  into  a  soluble  material  called  maltose.  It  is 
soluble  in  water  and  weak  alcohol,  insoluble  in  stronger  alcohol.  Its 
advantage,  as  compared  with  similar  ferments  in  the  saliva  and  pan- 
creatic juice,  is  considerable,  and  its  strength  enables  it  to  dissolve 
starches  when  present  in  the  proportion  of  only  i  to  2,000.  Like  the 
above-named  ferments,  it  acts  in  alkaline  solution,  but,  unlike  them, 
it  continues  to  operate  in  acid  media ;  hence  its  action  is  not  dis- 
turbed by  the  gastric  juice.  Diastase  is  the  peculiar  substance  which 
causes  the  ripening  during  germination  of  fruits  and  vegetables  by 
converting  their  starches  into  dextrins  and  sugars.  Hence  fruit 
becomes  more  and  more  digestible  as  it  ripens. 

In  prescribing  diastase  or  malt  extract  it  should  be  remembered 
that  the  ferment  is  precipitated  and  destroyed  by  alcohol  of  even  mod- 
erate strength,  and  also  by  salicylic  acid,  which  is  antagonistic  to  it. 

When  malt  is  added  to  a  pease  pudding  or  other  mashed  vege- 
table, it  separates  the  mass  into  a  paste  of  cellulose  and  vegetable 
casein,  with  a  supernatant  solution  of  dextrin. 

Williams  recommends  the  use  of  malt  flour  with  cereal  foods  to 
render  them  more  digestible.  Malt  flour  alone  is  too  sweet,  but, 
added  in  the  proportion  of  one  part  to  four  or  eight  of  oatmeal,  it 
makes  an  excellent  light,  thin  porridge  for  invalids. 

A  variety  of  malt  extracts  and  malted  foods  are  prepared  for  in- 
valids, and  many  of  them  possess  intrinsic  value  for  nutrition  and 
tonic  action.  They  are  especially  useful  in  chronic  and  subacute  ail- 
ments and  convalescence  from  protracted  fevers.  They  are  benefi- 
cial in  tuberculosis,  caries,  chronic  abscess,  neurasthenia,  the  scrofu- 
lous diathesis,  typhoid  fever,  and  to  some  extent  they  can  be  used 
as  beverages  to  replace  the  stronger  malt  liquors,  ale,  beer,  etc. 


VEGETABLE  FOODS. 


143 


All  fnalted  foods  are  deficient  in  fats  and  proteids.  Farinaceous 
meal  of  any  kind  mixed  with  one  eighth  of  its  weight  of  ground 
malt  forms  a  highly  digestible  combination.  Even  20  per  cent  of 
meal  can  be  used,  and  the  preparation  still  keeps  fluid  (Roberts). 

Kepler  s  Extract  of  Malt  is  given  in  the  dose  of  a  teaspoonful 
after  meals  in  milk  or  soda  water,  or  it  may  be  spread  upon  any 
form  of  starchy  food. 

Loeflund's  Malt  Extract  is  given  in  doses  of  a  dessertspoonful 
after  meals  in  a  gobletful  of  milk. 

Maltine  is  made  from  three  cereals — barley,  wheat,  and  oats.  It 
is'rich  in  diastase.  It  may  be  added  in  the  proportion  of  one  half  to 
wheat  or  barley  flour  which  has  been  previously  boiled  in  water,  and 
the  mixture  may  be  used  as  a  diluent  of  milk.  Maltine  may  be 
taken  after  meals,  either  plain  or  added  to  cod-liver  oil,  coca  wine, 
pancreatin,  hypophosphites,  etc.,  for  use  in  tuberculosis  and  other 
diseases. 

Hoff's  Malt  Extract  is  given  in  doses  of  a  wineglassful  or  more 
with  meals  for  adults,  and  one  or  two  tablespoonfuls  for  children. 
It  contains  considerable  diastase,  a  minimum  of  alcohol  (about  2 
per  cent),  and  is  said  to  be  free  from  noxious  ingredients.  It  may  be 
drunk  warmed,  with  a  lump  of  sugar  added,  as  a  soothing  draught 
to  allay  cough.  If  desirable  for  feeble  stomachs,  it  may  be  diluted 
with  water  or  soda  water. 

Trommer's  Diastatic  Extract  of  Malt  is  composed  of  the  soluble 
ingredients  of  Canada  barley  malt.  It  is  of  a  sirupy  consistence 
and  has  a  sweetish  taste,  which  some  patients  object  to,  while  many 
prefer  it.  The  sweetness  may  be  lessened  or  disguised  by  dilution 
with  water,  hot  milk,  brandy,  whisky,  or  rum.  It  is  advisable,  if  the 
stomach  is  feeble,  to  give  teaspoonful  doses  at  first,  to  be  increased 
to  a  tablespoonful  three  times  a  day  after  meals. 

Pancreatic  extract  or  three  to  five  grains  of  pancreatin  with  five 
grains  of  sodium  bicarbonate  may  be  added  to  a  cupful  of  thick,  well- 
boiled  farinaceous  gruel  of  any  sort — oatmeal,  cornstarch,  etc. — 
and  if  kept  at  100°  F_for  a  few  minutes,  the  mass  is  soon  liquefied 
and,  made  digestibje.  The  hydrated  starch  has  been  converted  into 
dextrin  and  sugar.  There  is  little  or  no  alteration  produced  in  taste, 
and  if  starch  is  to  be  given  to  an  infant  under  a  year  old  for  any 
purpose,  it  may  be  prepared  in  this  manner. 

Vegetable  Food. 

Nearly  all  the  great  divisions  of  the  vegetable  kingdom  afford 
wholesome  food  for  man. 

Vegetable  food  eaten  in  large  quantity  increases  the  elimination 
of  carbon  dioxide  from  the  lungs.  It  also  makes  the  urine  alkaline 
and  intensifies  the  alkalinity  of  other  secretions.     The  urine  of  her- 

13 


144 


FOODS   AND   FOOD   PREPARATIONS. 


bivorous  animals  is  normally  alkaline  when  they  are  well  fed,  but 
during  prolonged  fasting  it  becomes  acid.  The  nursing  calf  when 
taking  only  animal  food  from  the  mother  passes  acid  urine,  but  after 
weaning,  when  the  animal  changes  to  a  vegetable  diet,  the  reaction 
becomes  alkaline. 

The  chief  vegetable  proteids  are  vegetable  albumin,  vegetable 
casein  or  legumin,  and  gluten.  The  latter  predominates  in  the  cerea- 
lia,  and  the  legumin  is  principally  found  in  pulses.  These  ptoteids 
are  less  rich  in  nitrogen  than  the  corresponding  animal  albumi- 
nates. 

Many  vegetables  contain  tough  cellulose,  and  at  best  not  over  50 
per  cent  of  this  material  is  digested  and  assimilated  in  man,  although 
the  lower  animals  derive  much  more  nutriment  from  it.  Cellulose 
added  to  meat  interferes  with  its  complete  digestion  (Hoffmann). 

A  purely  vegetable  diet  is  not  economical  for  a  labouring  man, 
for  the  reason  that  to  derive  sufficient  nitrogenous  substance  from  it 
he  must  either  obtain  the  very  best  and  most  expensive  cereals  or 
legumes,  or  he  must  eat  a  very  large  quantity  of  vegetables.  By  the 
addition  of  albuminous  food  or  fat  to  his  diet  he  saves  both  expense 
and  wear  and  tear  of  his  digestive  organs.  If  unable  to  obtain  fresh 
meat,  he  may  employ  for  this  purpose  milk,  bacon,  lard,  dried  fish, 
such  as  herring  or  cod.  Apiong  vegetable  foods  oatmeal  and  beans 
will  furnish  him  with  the  largest  available  proportion  of  nitrogenous 
material.  Vegetables,  except  those  which  are  really  seeds,  such  as 
those  of  the  leguminosae  or  pulse  tribe,  contain  but  little  fat. 

A  strict  classification  of  vegetables  is  impossible  in  these  pages. 
Green  corn  is  certainly  a  vegetable,  but  it  is  more  conveniently 
described  in  connection  with  corn  meal,  samp,  etc.,  among  the  cereals 
(see  Maize). 

Certain  vegetables  are  classed  as  "green  vegetables,"  meaning 
the  lighter  kinds  of  vegetables  which  contain  considerable  earthy 
salts  and  comparatively  little  starch,  like  spinach  and  lettuce,  in  dis- 
tinction from  heavy  vegetables  which  contain  much  starch,  like  pota- 
toes, beans,  etc.  The  former  term  is  used  to  describe  fresh  garden 
vegetables  of  all  kinds  in  distinction  from  those  which,  like  potatoes 
or  onions,  may  be  kept  for  some  days  or  weeks  without  spoiling. 
The  name  is,  however,  too  vague  for  accurate  description. 

"  Greens "  is  the  common  name  given  to  such  vegetables  as 
spinach,  lettuce,  beet  tops,  etc.,  which  contain  much  chlorophyll  and 
little  starch  or  sugar,  and  which  are  eaten  soon  after  being  taken 
from  the  garden. 

A  very  simple  division  of  vegetables  to  give  to  some  patients  is 
(a)  those  which  grow  above  ground  and  {l>)  those  which  grow  below 
ground.  With  but  few  exceptions,  like  the  legumes,  corn,  and  cab- 
bage, the  heavier  vegetables — i.  e.,  those  which  require  more  digestive 


VEGETABLE   FOODS. 


145 


power,  and  whicli  contain  abundant  starch  or  sugar — grow  below 
ground,  or  are  tubers.  Those  which  grow  above  ground  are  more 
digestible  when  fresh  and  young. 

Celery,  however,  is  not  a  tuber,  is  not  especially  "  starchy,"  and 
yet  grows,  in  part  at  least,  beneath  the  earth ;  so  it  is  best  in  all  im- 
portant cases  to  specify  by  name  the  individual  vegetables  which  can 
be  partaken  of  rather  than  to  describe  them  in  general  classes. 

Many  vegetables,  in  themselves  difficult  of  digestion,  may  be 
made  less  so  by  conversion  into  well-cooked  purees,  or  their  extracts 
can  be  used  for  flavouring  broths  and  soups  for  invalid  use.  Gener- 
ally speaking,  dried  vegetables  are  much  less  digestible  than  when 
fresh.     They  become  hard,  stringy,  and  tasteless. 

The  following-named  vegetables  are  those  in  common  use  which 
contain  the  largest  percentage  of  both  starches  and  sugars :  Pota- 
toes (both  white  and  sweet),  yams,  beans,  lentils,  corn,  peas,  carrots, 
parsnips,  beets,  turnips. 

Vegetable  foods  which  are  somewhat  stimulant  or  pungent  in 
their  action  are  leeks,  onions,  garlic,  herbs  in  general,  mustard, 
cresses,  mints,  asparagus,  and  radishes.  They  increase  the  secretion 
of  the  saliva  and  gastric  juice,  and  several  are  somewhat  diuretic. 

Some  vegetables  are  laxative  on  account  of  their  special  chemical 
composition.  Such,  for  example,  are  spinach,  tomatoes,  and  most 
green  vegetables  when  fresh  and  well  cooked.  Some,  like  cucumbers, 
are  laxative  from  the  seeds,  or,  like  old  corn,  from  the  indigestible 
residue  which  they  contain.  The  heavier  vegetables,  such  as  peas, 
beans,  turnips,  potatoes,  etc.,  are  more  apt  to  be  constipating,  al- 
though they  aid  normal  peristalsis  in  that  class  of  cases  in  which  the 
.diet  has  been  previously  mainly  nitrogenous  (see  Dietetic  Treatment 
of  Constipation). 

Vegetables  which  have  a  special  antiscorbutic  reputation  are  cab- 
bage, tomatoes,  and  all  those  used  for  fresh  salads.  These  also  fur- 
nish calcium  oxalate  in  the  urine. 

All  vegetables  which  are  eaten  raw  should  be  thoroughly  washed 
beforehand ;  otherwise  they  may  be  contaminated  with  manure  and 
other  impurities,  or  the  excrement  of  domestic  animals  which  have 
been  roaming  in  the  garden.  The  larvae  of  both  tapeworms  and 
roundworms  have  been  transmitted  to  man  in  this  manner.  Water 
from  foul  wells  is  sometimes  used  for  sprinkling  gardens,  and  it  is 
possible  for  typhoid,  cholera,  or  other  noxious  germs  to  be  spread 
by  this  means  when  the  vegetables  are  eaten  raw. 

Legumes. 
Peas,  Beans,  Lentils. — Owing  to  the  exceedingly  leathery  ex- 
ternal envelope  which  they  possess  when  old,  legumes  are  very  indi- 
gestible unless  cooked  for  a  long  time,  and  if  dried  they  require  pre- 


146 


FOODS   AND   FOOD   PREPARATIONS. 


vious  prolonged  soaking  in  cold  water,  for  drying  diminishes  their 
size  and  makes  them  extremely  tough. 

Dried  or  "  split "  peas  have  had  this  envelope  removed,  and  they 
may  be  made  into  nutritious  purees.  The  tough  external  coats  of 
old  peas  may  often  be  found  wholly  unaltered  in  the  faeces. 

According  to  Parkes,  a  pound  of  peas  contains  168  grains  of  starch, 
and  about  6.5  per  cent  of  this  food  is  wasted  in  the  alimentary  canal. 

Fresh  very  young  green  peas,  petit  pois,  are  easily  digested,  and 
may  occasionally  be  allowed  in  a  convalescent  dietary,  but  old  and 
tough  legumes  require  more  mastication  even  than  meat. 

The  legumes  are  often  cooked  with  pork,  which  raises  the  per- 
centage of  fat  in  this  form  of  food  and  adds  to  their  nutritive  value. 
Baked  beans  are  cooked  in  this  way,  and  also  pea  soup ;  the  swelling 
starch  granules  mingle  with  the  melting  fat  of  the  pork  and  make 
the  dish  more  palatable  as  well  as  much  more  digestible  than  when 
this  fat  is  added  to  meat  in  the  form  of  croquettes  or  mince,  when  it 
merely  smears  the  outside  of  the  larger  particles  of  food. 

Erbswurst,  or  pea  sausage,  was  introduced  some  years  ago  in  the 
German  army.  It  was  invented  in  1870  by  a  cook  named  Griinberg, 
and  the  German  Government  bought  the  secret  of  its  preparation. 
It  is  a  cooked  food  composed  of  pea  meal  mixed  with  fat  pork  and 
salt,  so  treated  as  to  prevent  the  decay  of  legumin.  It  is  highly  nu- 
tritious, for  the  peas  contain  a  large  proportion  of  nitrogenous  as 
well  as  starchy  material,  and  the  fat  furnishes  energy,  but  as  a  diet 
it  soon  becomes  monotonous  and  not  infrequently  produces  flatu- 
lence and  diarrhoea  effects,  for  which  the  legumes  are  noted.  The 
flatulence  is  caused  by  liberation  of  sulphuretted  hydrogen  from  a 
substance  called  legumin. 

Erbswurst  may  be  quickly  made  into  soups.  It  figured  largely 
in  the  Franco-Prussian  War,  and  was  known  as  the  "iron  ration." 
A  powdered  "pea  soup  "  may  now  be  obtained  which  is  composed  of 
powdered  peas  and  extracts  of  bpef  with  salts  and  herb  extracts  for 
flavouring.  A  three-and-a-half-ounce  package  contains  in  grammes  : 
proteids,  21 ;  fats,  17.25  ;  carbohydrates,  46.5.  It  is  excellent  for 
army  service  in  the  field. 

Composition  of  some  Prepared  Military  Pea  Foods  (Woodruff). 


Water. 

Protein. 

Fat. 

Carbo- 
hydrates. 

Wood 
fibre. 

Ash. 

Authority. 

Erbswurst 

12.09 

31-18 
16.00 
15-70 
16.93 
15-81 
21.09 

3-08 
35-00 
23.00 

8.98 
24.41 
17-25 

47-50 
27.00 

53-44 
36.78 

46-45 

1-34 
1.69 
4.40 

6.15 

11-73 

13-53 

6.03 

Blythe, 
Parkes. 

"         as  first  used. 
1887 

Dried  pea  soup  (i).. . . 

"        "       "      (2).... 
Kopfs  "       "   (used  by 

the  English  army). 

7-58 
8.08 
4.78 

Konig. 
S.  P.  Sharpless 

PLATE  VIT. 


«>  |» 


*v«?s'8  .irOrs 


Bean  Starch       x  145 


Pea  Starch       x  145 
(f^om  Bulletin  No.  13,  Divmxm  of  Chemitiry,  United  StaU:»  AgricuUunU  Bureau). 


IIOTO    BY  I'LlrroHll   KIIHARIISON. 


VEGETABLE   FOODS. 


147 


Penzoldt  has  succeeded  in  obtaining  predigested  vegetable  albu- 
min by  the  following  receipt: 

Finest  pea  meal 250.0  grammes. 

Pepsin V 0.5  gramme. 

Salicylic  acid i .  o         " 

Mix  and  let  stand  at  100°  F.  for  twenty-four  hours  ;  strain. 

The  fluid  retains  the  taste  of  pea  soup,  and  is  quite  free  from 
starch.  It  may  be  added  to  meat  extracts  or  eggs,  and  may  be  fla- 
voured with  salt,  pepper,  and  spices. 

Haricot  or  kidney  beans  constitute  a  very  serviceable  article  of  diet, 
being  one  of  the  cheapest  and  best  of  all  the  pulses.  These  beans 
must  be  thoroughly  soaked  until  swollen  and  soft  before  boiling,  and 
should  be  only  eaten  when  wholly  tender.  Their  flavour  is  height- 
ened by  the  addition  of  a  little  onion,  parsley,  or  other  aromatic 
vegetable,  and  their  nutritive  value  is  increased  by  cooking  them  with 
pork. 

Fresh,  young,  and  tender  string  beans  are  very  digestible. 

Young  fresh  Lima  beans  are  wholesome  and  very  nutritious,  but 
if  old  they  are  quite  indigestible. 

Lentils. — Lentils  grow  in  the  south  of  France,  and  also  near  Paris. 
They  are  usually  dried  and  split,  in  which  condition  they  make  an 
excellent  and  nutritious  soup. 

They  are  used  more  on  the  Continent  of  Europe  than  in  this 
country,  and  to  some  extent  they  are  eaten  in  England,  usually  in 
the  form  oi  pur^e. 

They  are  sold  under  the  name  of  "  ravelenta  arabica  "  of  which 
they  form  an  ingredient  (p.  140).  Their  taste  is  somewhat  bitter, 
and  on  that  account,  unless  disguised  by  some  other  vegetable  fla- 
vour, they  ^e  disliked  by  many  persons. 

Like  the  other  legumes,  they  contain  proteid  material  and  fat,  and 
are  quite  nutritious. 

Roots  and  Tubers. 

Roots  and  tubers  constitute  a  very  important  class  of  vegetable 
foods.  They  contain  both  starch  and  sugar  as  well  as  a  little  pectin 
and  potash  salts.  They  have  much  less  albuminous  material  than  is 
to  be  found  in  any  other  forms  of  starchy  food,  and  they  also  hold 
a  large  percentage  of  water.  Many  of  them  are  very  nutritious 
and  even  fattening,  but  in  proportion  to  their  bulk  they  afford  less 
actual  nutriment  than  either  the  legumes  or  cereals. 

Potatoes. — The  potato  ranks  first  in  importance  among  the  class 
of  tubers  which  serve  man  for  food,  both  on  account  of  its  easy  cul- 
tivation in  a  great  variety  of  soils  and  on  account  of  its  easy  digesti- 
bility, when  properly  cooked.  As  an  exclusive  article  of  diet  the 
potato  is  too  largely  composed  of  starch  to  be  of  much  nutritive 


1^8  FOODS   AND    FOOD    PREPARATIONS. 

value,  and  enormous  quantities  have  to  be  eaten  (several  pounds  a 
day)  in  order  to  supply  enough  nitrogen  for  the  energy  of  the  body. 
In  Ireland  this  form  of  vegetable  constitutes  a  greater  proportion  of 
the  daily  food  than  in  almost  any  other  country,  and  in  periods  of 
famine  has  been  known  to  form  four  fifths  of  the  entire  food  for  a 
time,  but  of  late  years  it  has  been  largely  supplemented  by  the  cul- 
tivation of  Indian  corn  and  other  products.  The  flavour  and  quality 
of  the  potato  is  influenced  very  much  by  the  soil  and  climate  in 
which  it  grows,  a  sandy  soil  being  best. 

Konig  gives  the  percentage  composition  of  the  potato  as  water, 
75.77;  nitrogenous  materials,  1.79  (others  give  2.10);  fat,  1.60; 
starch,  20.56  ;  cellulose,  0.75  ;  ash,  0.97.  It  is  thus  seen  to  contain 
about  one  fourth  solid  matter. 

The  potato  becomes  a  much  more  strengthening  food  when  eaten, 
as  it  usually  is,  with  meat  gravy,  fat,  or  butter  and  salt. 

Potato  juice  has  a  faintly  acid  reaction,  and  its  vegetable  acids 
are  mainly  combined  with  salts  of  potassium,  but  also  with  sodium 
and  calcium.  It  also  contains  traces  of  iron,  phosphoric  and  sul- 
phuric acids,  chlorine,  silica,  and  magnesia.  Owing  to  the  large 
proportion — from  12  to  24  per  cent — of  nearly  pure  starch  which 
is  found  in  the  potato,  it  is  very  extensively  used  in  this  country  and 
elsewhere  for  the  manufacture  of  laundry  starch.  Old  potatoes,  and 
those  which  have  been  long  kept,  show  some  alteration  in  the  quan- 
tity of  their  starch,  and  a  part  is  converted  into  sugar  and  gum. 

Potato  starch,  as  compared  with  other  starches,  is  thoroughly 
digestible,  but  much  depends  upon  the  cooking.  The  starchy  gran- 
ules are  tough  and  absorb  water  from  the  acid  juices  which  surround 
them  and  from  water  added  in  cooking,  and  when  properly  prepared 
the  potato  becomes  soft  and  mealy.  When  this  is  not  the  case,  how- 
ever, it  remains  hard  and  soggy,  and  is  thoroughly  indigestible. 

The  following  statement  in  regard  to  the  potato  is  made  in  a  re- 
cent report  of  the  British  Commissioners  of  Prisons: 

"Within  and  surrounding  the  cells  is  a  fluid  or  juice  the  albumi- 
nous constituents  of  which  are  coagulated  during  the  process  of  cook- 
ing. The  watery  part  of  this  juice  is  absorbed  by  the  starch  gran- 
ules, which  swell  up  and  distend  the  cells  in  which  they  are  con- 
tained, so  that  they  no  longer  adhere  together,  and  the  result  is  the 
loose  flocculent  mass  which  is  described  as  a  floury  or  mealy  potato. 
Unless  the  potato  be  properly  cooked,  the  fluid  referred  to  is  only 
partially  absorbed,  the  cells  do  not  become  sufficiently  distended  and 
separated,  and  the  potato  is  then  described  as  'waxy'  and  'dense.' 
In  this  condition  it  is  not  digested,  and  consequently  does  not  fur- 
nish to  the  system  the  antiscorbutic  principle  in  which  resides  its 
chief  value  as  an  article  of  diet." 

When  potatoes  are  cooked  in  water,  it  is  desirable  not  to  remove 


PLATE  VIII. 


POTATO  Starch       x  43 


Potato  Starch 


{F¥om  HulUtin  So.  13,  LHvwion  of  ChemiMry,  Unik'd  SUiU:»  AgricuUunU  Bureau). 


I'IKiTO    BY  >  I.ItKi'KI)  RIiHARrmilN. 


VEGETABLE   FOODS. 


149 


their  skins,  for  the  latter  prevent  to  a  great  extent  the  passage  of 
the  salts  out  into  the  fluid.  The  fact  that  potatoes  will  not  decay  if 
kept  dry  for  a  length  of  time  makes  them  very  useful  vegetables 
upon  sea  voyages,  when  their  antiscorbutic  properties  are  especially 
serviceable. 

Potatoes  are  more  digestible  when  cooked  by  baking  in  their 
skins  than  by  any  other  process.  They  then  become  mealy  and  their 
starch  is  digested  with  comparative  ease  by  invalids.  They  are  also 
quite  digestible  if  steamed,  or  if  boiled  and  mashed  through  a  colander. 

Potatoes  must  be  avoided  in  all  cases  of  feeble  digestion  unless 
they  are  perfectly  mealy  and  crumble  readily,  and  this  quality  de- 
pends not  alone  upon  the  method  of  cooking,  but  upon  the  nature  of 
the  potato  itself,  which  varies  according  to  the  soil  or  the  season  of 
the  year  in  which  it  has  been  grown.  Very  young  potatoes  are  not 
mealy.  They  require  more  cooking  and  are  less  digestible  than  those 
of  medium  age.  If  too  old,  on  the  other  hand,  potatoes  become 
waxy  and  equally  undesirable.  If  they  have  been  exposed  to  frost 
or  have  been  cultivated  in  a  damp,  boggy  soil,  their  digestibility  is 
much  impaired. 

Sweet  Potatoes. — The  variety  known  as  the  sweet  potato  contains 
somewhat  less  starch  than  the  white  potato,  having  but  16  per  cent, 
but  it  has  more  water,  and  a  larger  proportion  of  sugar — 10  per  cent. 
It  forms  a  valuable  and  decidedly  nutritious  food  which  is  eaten  ex- 
tensively throughout  the  United  States,  but  it  is  not  so  digestible  as 
the  white  potato,  for  it  cannot  always  be  obtained  in  a  mealy  form, 
and  is  sometimes  stringy  and  sodden.  A  flour  or  meal  can  be  pre- 
pared from  it  by  drying.  Its  use  in  Europe  antedates  that  of  the 
white  potato,  which  has  to  a  great  extent  superseded  it.  These  po- 
tatoes vary  much  more  in  flavour  than  do  the  white.  In  general, 
they  should  not  be  given  to  invalids. 

The  yam^  another  form  of  tuber,  is  eaten  in  the  tropics  and  in 
some  parts  of  Europe.  It  is  mealy,  but  not  very  sweet,  and  it  con- 
stitutes a  wholesome  and  thoroughly  digestible  food. 

The  Jerusalem  artichoke,  or  ground  pear,  is  a  tuber  belonging  to 
the  sunflower  family,  which  was  originally  introduced  from  Brazil. 
It  is  used  more  commonly  in  England  than  elsewhere,  but  is  also 
sometimes  cultivated  in  the  United  States.  It  is  sweet  and  watery, 
for  it  contains  but  little  starch,  and  it  does  not  cook  "mealy."  It 
contains  more  sugar  than  the  sweet  potato,  having  14  per  cent  of 
sugar,  3  per  cent  of  nitrogenous  material,  and  2  per  cent  of  inulin 
(Yeo).  Its  nutritive  value  is  comparatively  slight,  but  it  is  easily 
digested. 

The  Beet  contains  among  its  solid  ingredients  between  85  and 
90  per  cent  of  starches  and  sugars,  a  trace  of  salts,  and  somewhat 
over  I  per  cent  of  proteid  matter.     It  is  a  common  source  of  sugar, 


150  FOODS  AND  FOOD  PREPARATIONS. 

which  when  refined  is  sometimes  less  sweet  than  cane  sugar,  but  is 
otherwise  as  good.  On  account  of  the  sugar  which  they  contain, 
beets  have  the  reputation  of  contributing  to  the  formation  of  fat 
in  the  body.  Young,  tender  beets  are  very  nourishing,  and  they 
are  often  eaten  in  the  form  of  salads  or  with  vinegar  and  oil,  and 
thus  contribute  a  useful  variety  to  the  diet. 

Succulent  Tubers. — There  is  a  group  of  succulent  roots  which 
contain  considerable  watery  juice  and  on  this  account  are  usually 
eaten  fresh,  for  if  kept  long  they  become  dry  and  less  palatable,  or 
are  apt  to  decay;  with  care,  however,  they  may  be  preserved  in  their 
natural  state  for  a  considerable  period.  They  are  very  digestible, 
and  when  thoroughly  boiled  are  nutritious.  They  are  carrot^,  pars- 
nips, turnips,  and  salsify.  To  these  may  be  added  the  radish  as  be- 
longing to  the  same  type,  although  it  is  too  pungent  to  be  eaten 
otherwise  than  as  a  relish,  and  on  account  of  its  flavour  it  is  pre- 
ferred raw. 

Carrots  consist  of  upward  of  85  per  cent  of  water,  with  a  small 
proportion  of  salts,  8  per  cent  of  carbohydrates  with  some  sugar,  and 
about  I  per  cent  of  proteid.  The  outer  layers  of  the  carrot  contain 
a  material  called  pectin  that  can  be  obtamed  as  a  jelly  and  mixed 
with  fruit  or  meat  jelly  for  flavouring  invalid  diet. 

Young  carrots,  when  soft  and  friable,  if  boiled  are  very  tender 
and  highly  flavoured,  and  constitute  a  nutritious  food.  In  France 
and  Germany  they  are  more  popular  than  in  this  country  and  are 
cooked  with  other  vegetables,  although  somewhat  at  the  expense  of 
the  flavour  of  the  latter.  At  the  baths  of  Vichy  they  form  a  part  of 
the  daily  breakfast. 

Parsnips  contain  the  sugar  of  starch  with  a  large  percentage  of 
water,  and  they  are  sometimes  fermented  into  an  alcoholic  beverage. 
They  are  a  wholesome  although  less  used  food  than  carrots.  The 
parsnip  contains  over  90  per  cent  of  water  and  only  6  per  cent  of 
starch  and  sugar,  with  i  per  cent  of  proteid,  besides  other  materials. 
It  is  a  rather  strongly  flavoured  vegetable,  and  bulky  in  proportion 
to  its  nutritive  value.  It  is  extensively  used  for  feeding  cattle,  and 
when  young  and  properly  cooked  by  prolonged  boiling  and  season- 
ing it  is  a  good  food.  It  should  be  particularly  avoided  by  those 
persons  in  whom  there  is  any  tendency  to  flatulency,  which,  like  the 
legumes,  it  is  apt  to  produce. 

Turnips  are  less  nutritive  than  either  carrots  or  parsnips.  They 
should  never  be  eaten  by  the  sick. 

Kohl  rabi,  or  turnip-root  cabbage,  yields  an  overground  turnip, 
which  is  somewhat  astringent. 

Salsify,  or  oyster  plant,  is  a  root  which  has  a  mild  sweet  flavour 
somewhat  similar  to  the  parsnip,  and  is  an  excellent  food  of  easy 
digestibility. 


VEGETABLE   FOODS. 


151 


Radishes,  which  are  not  unlike  turnips  in  composition,  contain  a 
large  percentage  of  water  and  a  comparatively  small  amount  of 
starch.  This  vegetable  is  of  no  special  value  for  nutrition,  and  serves 
merely  as  a  relish.  Being  eaten  raw,  it  is  difficult  of  digestion,  and  is 
apt  to  produce  eructations.  It  has  some  reputation  as  an  anti- 
scorbutic. 

Green  Vegetables. 

Composition. — Green  vegetables  do  not  contain  much  nutriment 
in  comparison  with  the  cereals  and  tubers,  and  they  are  mainly  useful 
for  furnishing  a  pleasing  variety  in  diet  and  for  supplying  a  large 
proportion  of  salts  and  some  acids  which  are  believed  to  be  service- 
able in  the  prevention  of  scurvy.  The  various  uses  of  the  salts  have 
been  elsewhere  described  (see  p.  38).  These  vegetables  often  con- 
tain 90  per  cent  or  more  of  water,  which  in  itself  is  useful  to  the 
system  in  many  ways.  They  furnish  but  a  small  quantity  of  nitro- 
genous material,  which  varies  from  1.5  up  to  4  per  cent.  In  addition, 
they  contain  cellulose,  chlorophyll,  sugars,  gum,  pectin,  and  some- 
times a  little  fat.  Their  variety  of  taste  depends  upon  the  presence 
of  flavouring  materials,  chiefly  essential  oils.  As  a  rule,  they  have  a 
better  flavour,  and  are  more  digestible  when  young  than  old,  when 
they  become  tough  and  "  stringy  "  from  a  relatively  large  percentage 
of  cellulose  or  woody  fibre.  Since  the  green  vegetables  afford  so 
little  nutriment  in  proportion  to  their  bulk,  they  are  not  of  much 
service  for  persons  with  feeble  digestion,  and,  unless  they  are  young 
and  tender,  they  are  positively  harmful  by  overtaxing  the  digestive 
system  and  irritating  the  alimentary  canal.  On  the  other  hand,  they 
are  very  useful  in  overcoming  constipation  by  their  bulky  waste 
matter,  which  acts  as  a  mechanical  stimulus  to  peristaltic  action  and 
promotes  movement  of  the  bowels. 

The  digestibility  of  these  vegetables  is  rendered  much  greater  by 
careful  cultivation  in  suitable  soils.  Owing  to  the  large  quantity  o£ 
water  which  they  hold  (which  readily  evaporates),  they  soon  wilt  or 
become  dry  in  market.  For  the  most  part  they  should  be  eaten  when 
quite  fresh,  although  winter  cabbage  is  an  exception  to  this,  as  it 
may  be  kept  for  weeks. 

Fresh  green  vegetables  as  well  as  roots  or  tubers  are  always  made 
more  digestible  by  cooking,  which  softens  them.  Their  most  diges- 
tible form  for  invalids  is  that  oi  purees. 

Cabbagfes. — The  cabbage  family,  which  belongs  to  the  natural 
order  Cruci/ene,  furnishes  many  examples  of  green  vegetables,  some 
of  which  are  of  value  for  their  leaves,  and  others  for  their  modified 
flowers.  There  are  about  seventy  varieties  of  cabbages.  They  con- 
tain considerable  sulphur,  which,  if  malfermentation  exists  in  the 
alimentary  canal,  produces  sulphuretted  hydrogen,  causing  flatulence 
and  unpleasant  odour.     They  also  give  rise  to  calcium  oxalate  in  the 


152 


FOODS  AND   FOOD   PREPARATIONS. 


urine,  and  they  should  be  avoided  by  the  rheumatic  or  gouty,  and,  in 
fact,  by  all  classes  of  invalids.  Cabbages  and  other  vegetables  of 
this  order  impart  a  strong  taste  and  odour  to  the  water  used  for 
boiling  them.  When  soft  and  crisp,  cabbage  is  a  wholesome  food  for 
those  with  strong  digestion,  and  it  has  decided  antiscorbutic  proper- 
ties when  fresh,  which  are  lessened  by  fermentation. 

The  principal  edible  representatives  and  preparations  of  the  cab- 
bage family  are  the  following : 

1.  Sauerkraut  is  made  by  placing  salt  between  layers  of  cabbage 
leaves  and  subjecting  them  to  pressure,  which  bruises  them  and 
squeezes  out  their  juices.  The  mass  then  ferments  with  the  forma- 
tion of  acids. 

2.  Cauliflower  and  broccoli  are  the  flowers  of  the  plants  which  are 
grown  large  and  tender  by  cultivation.  When  boiled  and  served 
with  a  milk  sauce  they  are  much  esteemed  for  their  flavour  and  easy 
digestibility  in  healthy  stomachs,  but  they  cause  flatulence  if  eaten 
by  dyspeptics.  These  vegetables  may  be  dressed  with  olive  oil  and 
eaten  as  a  salad. 

3.  Coleslaw  is  sliced  cabbage  served  as  a  salad. 

4.  Seakale  is  grown  in  the  dark  so  that  it  has  no  chlorophyll.  It 
is  equally  digestible  with  the  cauliflower  if  well  bleached.  It  is  more 
often  cultivated  in  England  than  in  this  country. 

Spinach,  beet  tops  or  greens,  dandelion  tops,  and  turnip  tops  are 
all  useful  green  vegetables,  and  of  these  spinach,  which  is  slightly 
acid,  is  the  most  common  and  desirable.  These  substances  afford 
almost  no  nutriment,  and  are  valuable  chiefly  for  their  laxative  action. 
If  the  leaves  are  young  and  tender,  and  if  they  are  cooked  until  they 
become  quite  soft  and  are  then  chopped  into  a  fine  pulp,  they  are  very 
wholesome  articles  of  food  for  the  relief  of  chronic  constipation.  The 
dandelion  leaves  have  a  less  delicate  flavour  than  spinach,  and  are 
said  to  possess  a  slight  diuretic  action.  Unless  bleached  they  are 
apt  to  be  bitter.  The  dandelion  root  is  laxative,  like  the  leaves,  and 
it  forms  an  ingredient  of  root-beer. 

Lettuce,  etc. — There  is  a  group  of  vegetables  of  which  lettuce  is 
the  chief  type,  the  leaves  of  which  are  eaten  raw.  They  are  useful 
for  their  flavour  and  for  the  variety  which  they  furnish  in  the  course 
of  a  meal.  They  cannot  be  said  to  possess  any  nutrient  value,  but 
they  are  usually  taken  with  vinegar  and  oil,  and  the  latter  is  very 
nourishing.  Since  they  contain  but  little  starch  and  practically  no 
sugar,  they  may  be  allowed  in  the  diabetic  regimen. 

Sorrel  and  cress,  or  peppergrass,  are  used  in  the  making  of  salads, 
but  less  in  this  country  than  in  Europe.  Sorrel  has  a  somewhat  pun- 
gent or  acid  flavour,  which  is  due  to  acid  oxalates,  and  this  fact  ren- 
ders it  unfit  for  use  by  patients  who  are  subject  to  attacks  of  gout 
and  rheumatism  or  who  have  the  uric-acid  diathesis. 


VEGETABLE   FOODS. 


153 


Many  other  substances  are  mentioned  in  works  on  dietetics  which 
are  used  in  the  making  of  salads  or  pickles  and  as  relishes.  They 
are  antiscorbutic  and  serve  to  stimulate  the  digestive  secretions  and 
give  a  fillip  to  the  appetite.  Such  are  green  peppers,  capers,  mint, 
tarragon  (an  aromatic  Siberian  plant),  parsley,  chervil,  endive,  chicory, 
okra. 

Celery  is  a  wholesome  vegetable  when  cooked  in  milk  until  it  is 
quite  soft ;  but  eaten  raw  it  is  stringy,  and,  as  it  has  but  little  nutri- 
tive value,  its  use  in  that  form  should  be  discarded  by  invalids.  Its 
aromatic  flavour  makes  it  very  popular,  and  it  furnishes  a  useful 
addition  to  a  light  luncheon  with  bread  and  cheese.  It  has  acquired 
an  undeserved  reputation  for  use  in  rheumatism.  "  Celery  salt  "  is 
an  agreeable  flavouring  substance  for  soups  and  salads.  Various 
preparations  are  made  from  the  plant,  which  are  sold  by  druggists  as 
hypnotics.     They  are  of  no  value. 

Artichokes  are  a  variety  of  thistle.  They  contain  tannin  and  mu- 
cilaginous materials,  but  nothing  of  true  nutrient  power,  although, 
according  to  Moleschott,  they  hold  17.75  P^^  cent  of  organic 
matter. 

Green  artichokes  when  tender  and  thoroughly  cooked  are  easily 
digested,  but  their  cost  in  this  country  prevents  them  from  being 
consumed  except  as  an  article  of  luxury.  They  may  be  given  to 
some  diabetic  patients  among  the  few  vegetables  which  they  can  eat 
with  impunity.  Eaten  raw,  as  they  sometimes  are  ir^  France,  they  are 
very  indigestible. 

Tomatoes. — The  tomato  is  a  vegetable  which  was  introduced 
into  this  country  about  fifty  years  ago,  the  value  of  which  is  becoming 
more  and  more  appreciated.  In  Germany  it  is  still  sold  as  a  fruit  of 
luxury  rather  than  as  a  common  vegetable.  It  is  wholesome  when 
eaten  raw  as  a  salad  with  vinegar  and  oil,  and  it  forms  a  popular  in- 
gredient of  strong  condiments,  such  as  tomato  catsup.  It  is  refresh- 
ing, slightly  acid,  and  easily  digested.  The  oxalic  acid  which  it  con- 
tains makes  it  injurious  in  cases  of  gout  or  the  uric-acid  diathesis. 
The  tomato  is  much  prized  as  a  canned  vegetable  on  account  of  the 
fact  that  it  retains  more  of  its  original  flavour  than  do  most  vege- 
tables preserved  by  this  process. 

The  eggplant  is  related  to  the  tomato,  and  like  it  contains  many 
seeds  when  full  grown,  but  it  is  much  less  digestible,  especially  when 
fried,  and  is  not  a  suitable  food  for  invalids. 

Cucumbers  are  mainly  eaten  raw,  and  they  should  be  young.  Like 
celery,  they  contain  too  much  woody  fibre  to  be  consumed  in  bulk. 
They  are  valuable  for  pickling  in  vinegar  or  in  the  making  of  chow- 
chow,  but  they  are  always  indigestible;  this  is  due  in  great  part 
^o  the  large  size  of  the  seeds  which  the  vegetable  contains,  and  it 
should  never  be  eaten  by  any  one  excepting  those  having  vigorous 


154 


FOODS   AND   FOOD   PREPARATIONS. 


Stomachs.  Eaten  raw,  even  in  small  quantities,  it  may  pioduce  vio- 
lent colic  and  diarrhoea. 

Asparagus  is  a  vegetable  possessing  a  very  deiicate  flavour,  and 
from  the  fact  that  it  is  among  the  first  of  the  fresh  vegetables  to  ap- 
pear in  the  early  spring  it  is  highly  esteemed.  When  young  and 
tender  it  is  very  digestible,  even  for  invalids.  The  greener  asparagus 
contains  more  bitter  and  resinous  principles*  than  the  white.  It  has 
been  claimed  that  it  possesses  some  influence  as  a  cardiac  sedative 
as  well  as  aphrodisiac  action,  but  these  properties  are  imaginary.  It 
is,  however,  slightly  diuretic,  and  it  owes  this  influence  to  a  substance 
called  asparagin,  which  may  be  obtained  in  crystalline  form.  Aspara- 
gus imparts  a  very  strong  and  disagreeable  odour  to  the  urine  which 
I  have  known  to  appear  within  an  hour  after  it  has  been  eaten,  and 
which  persists  from  twelve  to  twenty  hours.  It  is  caused  by  a  vola- 
tile sulphur  product,  a  methyl  mercaptan,  which  has  been  proved 
to  originate  in  the  intestine  during  digestion,  from  whence  it  is  ab- 
sorbed. 

Rhubarb,  or  "  pieplant,"  the  stems  of  the  leaves  of  which  are 
eaten  stewed,  is  an  excellent  vegetable.  The  flavour  is  quite  tart, 
and  the  fibre  is  stringy,  but  thorough  cooking  renders  it  soft  and 
digestible.  It  is  laxative,  and  is  therefore  useful  in  cases  of  chronic 
constipation.  This  wholesome  vegetable  has  not  received  the  atten- 
tion it  deserves.  In  Germany,  for  instance,  it  is  still  grown  merely 
as  an  ornamental  garden  plant  on  account  of  its  large  showy  leaves. 
It  produces  calcium  oxalate  in  the  urine  if  eaten  in  excess,  and  must 
therefore  be  avoided  in  oxaluria,  gout,  and  rheumatism. 

Pumpkins  and  squash  contain  much  water  and  a  good  deal  of 
coarse  fibre.  Tender  and  young  summer  squash  is  fairly  digestible, 
but  presents  no  special  dietetic  advantages.  The  pumpkin  is  one  of 
the  oldest  vegetables  on  this  continent,  and  it  was  grown  extensively 
together  with  maize  by  the  early  Indian  tribes. 

Onions,  garlic,  shallots,  and  leeks,  which  are  edible  both  as  fresh 
vegetables,  and  after  long  keeping,  are  useful  as  condiments  for  fla- 
vouring salads,  meat  stews,  and  other  foods.  They  are  also  eaten 
independently  for  their  nutritive  properties,  which  are  somewhat 
greater  than  those  of  the  four  or  five  vegetables  last  considered. 
Tender  young  leeks  and  white  onions  boiled  and  served  with  milk  or 
cream  are  very  wholesome  and  of  delicate  flavour.  They  possess,  in 
common  with  the  other  green  vegetables,  a  moderate  laxative  action, 
and  are  antiscorbutic.  They  impart  a  strong  typical  odour  to  the 
breath,  which  appears  within  two  or  three  hours,  and  if  the  individual 
is  constipated,  persists  for  twenty-four  hours  or  more.  This  is  due 
to  volatile  substances  which  are  absorbed  by  the  blood  from  the  ali- 
mentary canal  and  carried  to  the  lungs,  where  they  are  liberated. 

Vegetable  marrow  is  a  highly  succulent  vegetable,  somewhat  re-. 


VEGETABLE   FOODS. 


J.W 


sembling  the  pumpkin.     It  possesses  an  agreeable  flavour,  but  con- 
sists so  largely  of  water  that  it  is  of  scarcely  any  use  as  food. 

Cranberries  are  really  more  of  a  fruit  than  a  vegetable,  but  they 
are  usually  eaten  with  meat  as  a  vegetable.  They  are  serviceable 
for  their  agreeable  acidity  and  flavour,  but  unless  very  thoroughly 
cooked  and  made  into  a  jelly  with  much  sugar,  they  are  indigestible, 
for  their  outer  coatings  are  extremely  tough.  They  should  never  be 
given  to  invalids. 

The  composition  of  some  common  vegetables  is  thus  tabulated 
by  Moss : 

Composition  of  Vegetables. 


Constituents. 

Potato 
vPayen). 

Potato 

(Lethe- 

by). 

Sweet 
potato 
(Payen). 

Jerusa- 
lem ar- 
tichoke. 

Carrots 

(Lethe- 

by). 

Parsnips 

(Lethe- 

by). 

Turnips 

(Lethe- 

by). 

Cab-   , 
bage. 

Nitrogenous  matter 

Starch,  etc 

2.50 
20.00 
1.04 
1.09 
O.II 
1.26 

2.1 

18.8 

3-2 
0.2 
0.7 

75-0 

1.50 
16.05 
0.45 
10.20 
0.30 
2.60 
1. 10 

67. 50 

3-1 

1-5 

14.7 

0.2 

1-3 

0.9 

0.4 

1.9 

76.0 

1-3 

8.4 

0.2 

I.O 

83.0 

I.I 
9.6 

5-8 
0.5 
1.0 

82.0 

1.2 

5-1 

2.1 

o!6 
91.0 

2.0 

Cellulose 

0.5 
0.7 

Sugar  and  gummy  matter 
Fatty  matter 

Saline  matter 

Other  organic  matter.. . . 

Pectic  acid 

Pectin 

Inulin 

Water 

74. CO 

91.0 

Total 

100.00 

100. 0 

100.00 

100. 0 

100. 0 

100. 0 

100. 0 

100. 0 

The  following  analyses  of  common  vegetables  have  been  made 
by  Konig : 


Water 

Nitrogenous  matters.. . 

Fat 

Sugar 

Other   non-nitrogenous    ex- 
tractives  

Cellulose , 

Ash 


Carrots. 

Turnips. 

j 
Beet  root. 

88.32 

91.24 

87.07 

1.04 

0.96 

1-37 

0.21 

0.16 

0.03 

1.90 

4.08 

0.54 

7-17   . 

1.90 

9.02 

0.95 

0.91 

1.05 

0.71 

0.75 

0.92 

Celery. 


84.09 

1.43 

0.39 
0.77 

11.03 
1.40 
0.84 


Onions. 


85-99 
1.86 
o.io 

2.78 

8.04 
0.71 
0.70 


Cabbage. 


89.97 
1.89 
0.20 
2.29 

2.58 
1.84 
1.23 


Water 

Nitrogenous  matters 

Fat 

Sugar 

Other   non-nitrogenous    ex 

tractives 

Cellulose 

Ash 


Cauli- 
flower. 

Brussels 
sprouts. 

Spinach. 

Lettuce. 

Asparagus. 

90- 39 

85.63 

90.26 

94-33 

93-32 

2-53 

4.83 

3.15 

1. 41 

1.98 

0.38 

0.46 

0.54 

0.31 

0.28 

1.27 

0.08 

0.40 

3-74 

6.22 

3.26 

2.19 

2.34 

0.87 

1.57 

0.77 

0.73 

1. 14 

0.82 

1.29 

1.94 

1.03 

0.54 

French 
beans. 


88.36 

2.77 
0.14 
1.20 

6.82 
1. 14 
0.57 


1^6  FOODS   AND   FOOD   PREPARATIONS. 

The  two  preceding  tables  differ  slightly  in  detail,  but  no  rtiore 
than  the  average  variation  in  percentage  composition  of  the  vege- 
tables when  not  grown  under  identical  conditions.  They  agree  as 
nearly  as  can  be  expected. 

Fruits. 

Composition. — The  varieties  of  fruits  which  are  consumed  in 
all  countries  are  innumerable,  and  their  uses  are  various.  Sweet 
fruits  no  doubt  largely  composed  the  diet  of  primordial  man,  as  they 
do  of  every  savage  tribe  to-day  living  outside  .of  the  Arctic  Zone. 

Speaking  generally,  fruits  are  composed  largely  of  water  with 
starches,  sugars,  a  vegetable  jelly  called  pectin,  cellulose,  and  organic 
acids. 

Pectin  is  a  carbohydrate  substance  found  in  ripe  pulpy  fruits.  It 
enables  fruits  to  gelatinise  when  boiled.  Its  properties  and  com- 
position are  not  thoroughly  understood. 

The  organic  acids  exist  mainly  in  union  with  alkalies,  forming 
compounds  which  are  readily  split  up  in  the  system,  leaving  the  al- 
kalies free  to  combine  as  carbonates  or  phosphates. 

The  most  important  acids  are  citric,  malic,  and  tartaric,  which 
exist  in  various  quantities  and  combinations. 

Citric  acid  predominates  in  lemons,  limes,  and  oranges;  tartaric 
acid  in  grapes ;  malic  acid  in  apples,  pears,  peaches,  apricots,  goose- 
berries, and  currants. 

Among  the  least  acid  of  the  common  fruits  are  peaches,  sweet 
pears,  sweet  apples,  bananas,  and  prunes ;  moderately  acid  are  straw- 
berries.    The  most  acid  of  all  are  currants  and  lemons. 

Fruits  contain  a  smaller  proportion  of  earthy  salts  than  other 
foods. 

Certain  fruits  also  hold  a  little  nitrogenous  material,  chiefly  as 
albumins,  but,  as  a  rule,  the  starches  and  sugars  predominate,  and 
the  nutritive  value  of  any  fruit  depends  upon  them  chiefly.  Most 
fruits  contain  too  much  water  to  constitute  an  economic  diet  if  eaten 
alone.  Some  also  contain  a  small  quantity  of  fat  and  waxy  matter, 
and  most  of  them  have  more  or  less  pigment. 

Fruits  which  are  especially  rich  in  flavour,  and  which  exhale  a 
pleasant  aroma,  owe  these  conditions  to  the  various  essential  oils 
and  compound  ethers  which  they  possess  in  considerable  amount. 

Many  fruits  are  only  partially  edible  owing  to  the  fact  that  they 
are  composed  of  a  pulp  contained  within  an  indigestible  structure  of 
cellulose  or  woody  fibre. 

Fruits  are  commonly  classified  into  stone-bearing  fruits,  pomes, 
berries,  capsules,  and  pepos.  Some,  such  as  the  date,  the  plantain 
and  its  variety,  the  banana,  afford  sufficient  nutriment  to  amply  sup- 
port life  for  a  long  time ;  others,  like  the  apple,  are  wholesome,  but 


VEGETABLE   FOODS. 


157 


slightly  nutritious;  while  others  again  are  of  little  value  for  nutri- 
tive purposes,  and  are  mainly  serviceable  for  their  agreeable  flavour 
to  furnish  variety  in  the  diet. 

Composition  of  Fruits  (Bauer). 

Orange, 
pulp 
cnly. 


Water 

Nitrogenous  matters, 

Free  acids 

Sugar , 

Other       non  -  nitrogenous 

matters 

Cellulose  and  kernel 
Ash 


Apple. 

Pear. 

Peach. 

Grape. 

Straw- 
berry. 

Currant. 

83.58 

0.39 
0.84 

7-73 

83.03 
0.36 
0.20 
8.26 

83.03 
0.65 
0.92 

4.48 

78.18 
0.59 
0.79 

24.36 

87.66 
1.07 

.  0.93 
6.28 

84.77 
0.51 

2.15 
6.38 

5-17 
1.98 
0.31 

3-54 
4-30 
0.31 

7-17 
6.06 
0.69 

1.96 
3.60 
0.53 

0.48 
2.32 
0.81 

O.QO 

4-57 
0.72 

89.01 

0.73 
2.44 

4-59 

0.95 
1.79 

0.49 


Composition  of  Fruits  (Yeo). 


Apple. 

Cherry. 

Raisin. 

Fig. 

Water 

27-95 
1.28 
0.82 
3.60 
42.83 
17.00 
4-95 
1-57 

49.88 
2.07 
0.30 

32.22 

14.29 

0.61 

1.63 

32.02 
2.42 
0.49 

54.26 
7-4S 
1.72 
1. 21 

31.20 
4.01 

1.44 
I. 21 

Nitrogenous  matters 

Fat 

Free  acid 

Sugar 

49-79 
4.51 
4.98 
2.86 

Other  non-nitrogenous  matters 

Cellulose  and  seeds : 

Ash 

Fruits  arranged  According  to  the  Proportions  between  Acid,  Sugar,  Pectin, 
Gum,  etc.  (^Average).     (Fresenius.) 


Fruits. 


Plums 

Apricots 

Peaches 

Raspberries.. . . 

Currants 

Blackberries . . . 
Whortleberries. 
Strawberries . . . 
Gooseberries. .. 

Prunes 

Apples 

Sweet  cherries.. 

Grapes 

Red  pears 


Acid. 

Sugar. 

Pectin,  gum,  etc. 

1.6 

3-1 

1-7 

6.4 

2.3 

II. 9 

2-7 

I.O 

3-0 

0.1 

3-7 

1.2 

4-3 

0.4 

4.4 

0.1 

4-9 

0.8 

7.0 

4-4 

II. 2 

5-6 

17-3 

2.8 

20.2 

2.0 

94.6 

44.4 

Fruits  arranged  in  the  Order  of  their  Content  of  Sugar  (^Average). 

(Moss.) 

Peaches 1.6  per  cent. 

Apricots 1.8    "      " 

Plums 2.1    "      " 

Reineclaudes 3.1    '*      " 


1 53  FOODS  AND  FOOD  PREPARATIONS. 

Mirabelles 3-6  percent. 

Raspberries 4-0 

Blackberries 4-4  " 

Strawberries 5-7  "  " 

Whortleberries 5-8  "  " 

Currants 6.1 

Prunes 6.3  "  " 

Gooseberries 7-2  "  " 

Red  pears 7-5  "  " 

Apples 8.4 

Sour  cherries 8.8  "  " 

Mulberries 9.2  "  " 

Sweet  cherries 10.8  "  " 

Grapes 14-9  "  " 

Uses  and  Properties. — The  uses  of  the  different  fruits  may  be 
summed  up  as  follows: 

1.  To  furnish  nutriment. 

2.  To  convey  water  to  the  system  and  relieve  thirst. 

3.  To  introduce  various  salts  and  organic  acids  which  improve 
the  quality  of  the  blood  and  react  favourably  upon  the  secretions. 

4.  As  antiscorbutics. 

5.  As  diuretics,  and  to  lessen  the  acidity  of  the  urine. 

6.  As  laxatives  and  cathartics. 

7.  To  stimulate  the  appetite,  improve  digestion,  and  give  variety 
in  the  diet. 

8.  As  special  "  cures  "  for  certain  diseases,  like  the  grape  cure, 
although  their  specific  action  is  very  doubtful. 

Fruits  which  afford  the  most  nutriment  are  the  banana,  date,  fig, 
prune,  and  grape.  This  is  due  to  the  large  proportion  of  sugar  which 
they  contain. 

Fruits  which  contain  the  most  water  are  muskmelons,  water- 
melons, oranges,  lemons,  shaddocks,  and  grapes. 

The  antiscorbutic  value  of  fruits  is  illustrated  particularly  by  cer- 
tain varieties  which  furnish  abundant  potash  salts,  as  well  as  lime 
and  magnesia.  Among  these  are  to  be  mentioned  apples,  lemons, 
limes,  and  oranges. 

The  diuretic  influence  of  fruits  is  in  part  due  to  their  water,  but 
chiefly  to  their  organic  acids  and  salts,  which  stimulate  the  circula- 
tion and  probably,  also,  the  activity  of  the  renal  epithelium. 

Fruit  eating  lessens  the  acid  of  the  urine  or  even  makes  it  alka- 
line owing  to  decomposition  of  various  alkaline  salts  in  the  blood  or 
tissues,  which  are  reformed  into  alkaline  carbonate  and,  as  such,  are 
excreted.  For  this  reason  fruit  is  generally  believed  to  be  bene- 
ficial in  lithsemia,  gout,  and  allied  conditions  to  prevent  accumula- 
tion of  acid  urates. 

The  laxative  action  of  fruits  is  partially  derived  from  indigestible 


VEGETABLE   FOODS. 


159 


substances,  cellulose,  seeds,  etc.,  and  also,  no  doubt,  from  the  special 
influence  of  their  organic  ingredients,  which  in  some  instances  is  very 
striking. 

The  best  fruits  to  offset  constipation  are  fresh  apples,  figs, 
prunes,  peaches,  and  berries.  Dyspeptics  must  be  careful  to  avoid 
eating  all  hard  skins,  seeds,  or  coarse-fibred  fruits. 

Fruit  Ripening. — As  fruit  ripens  it  absorbs  more  and  more 
oxygen,  and  the  tannin  and  vegetable  acids  which  it  originally 
contained  are  altered,  so  that  it  becomes  less  astringent  and 
acid.  The  starch  i|  more  or  less  completely  turned  into  levu- 
lose  or  glucose,  and  soluble  pectin  is  formed.  The  aroma  and  taste 
of  ripe  fruits  depend  upon  the  relative  quantity  of  these  different 
substances,  together  with  various  volatile  ethers  and  oils.  The  sour 
fruits  have  either  more  acid  or  less  sugar,  and  in  the  sweet  fruits 
there  is  a  preponderance  of  sugar  which  masks  the  acid  taste.  The 
more  luscious  the  fruit,  the  more  soluble  sugars  and  special  flavour- 
ing substances  does  it  contain. 

The  employment  of  fruits  as  a  common  article  of  daily  diet  is 
highly  beneficial,  and  the  improvements  which  have  been  made  of 
late  years  in  methods  of  culture  and  means  of  rapid  transportation 
make  some  varieties  of  fresh  ripe  fruits,  such  as  the  orange  and  the 
banana,  available  in  almost  every  climate  in  all  seasons,  while  their 
mcreasing  cheapness  places  them  within  reach  of  the  poor. 

Fruit  Poisoning. — While  fruits  eaten  daily  and  in  proper  mod- 
eration are  very  wholesome,  if  they  are  eaten  too  freely,  or  if  they 
are  either  insufficiently  ripe  or  overripe,  soft,  and  decomposing, 
they  undergo  malfermentation  in  the  alimentary  canal,  and  are  al- 
most certain  to  cause  diarrhoea  with  colicky  pains,  cramps,  and  some- 
times nausea  and  vomiting.  Severe  attacks  of  gastritis  may,  espe- 
cially in  children,  be  produced  by  indulgence  in  unripe  apples,  pears, 
cherries,  berries,  etc.,  and  even  fatal  choleraic  diarrhoea  has  been 
occasioned  by  the  indiscriminate  consumption  of  fruits  which  have 
strongly  laxative  action.  After  such  fruit  poisoning,  emesis  should 
be  excited  if  the  patient  is  seen  in  time,  and  otherwise,  if  free  purga- 
tion has  not  occurred,  it  is  advisable  to  give  a  dose  of  castor  oil  or 
other  cathartic,  to  remove  the  irritating  substances  as  soon  as  pos- 
sible from  the  alimentary  canal.  In  bad  cases,  prolonged  gastric 
fever  may  ensue. 

When  to  Eat  Fruit. — Cooked  fruits  may  be  eaten  with  any 
meal,  but  usually  when  fruit  is  eaten  for  special  dietetic  purposes 
its  effect  is  always  more  pronounced  if  taken  alone,  either  at  the 
commencement  of  meals  or,  better,  between  them.  One  often 
observes  patients  who  can  obtain  no  laxative  effect  from  apples, 
figs,  and  other  fruit  eaten  as  dessert,  but  which  taken  at  night  into 
an  empty  stomach  or  an  hour  before  breakfast,  with  a  glass  or  two 
13 


l6o  FOODS  AND   FOOD  PREPARATIONS. 

of  cold  water,  has  a  very  pronounced  favourable  influence  upon  the 
bowels. 

The  poorest  time  for  eating  fruit  is  at  the  conclusion  of  a  very- 
hearty  dinner  at  which  considerable  variety  of  food  has  already 
been  consumed.  Fruit  in  general  is  less  wholesome  when  eaten  out 
of  its  natural  season.  All  fruits,  such  as  berries,  the  seeds  of 
which  are  eaten,  are  much  less  liable  to  produce  intestinal  irrita- 
tion if  taken  with  bread  or  other  bulky  starchy  food. 

Fruit  Soups. — In  Germany  fruit  soups  are  more  in  vogue  for 
general  use  than  in  this  country,  and  they  are  often  prescribed  in 
fevers  when  diarrhoea  does  not  exist.  Uffelmann  directs  that  for 
making  a  fruit  soup  one  part  of  fruit  to  four  or  five  of  water  may  be 
used,  and  Bauer  recommends  soups  "made  by  boiling  fresh  or  dried 
fruits  with  water,  with  or  without  the  addition  of  sugar,  lemon  peel, 
etc.,  and  freed  from  the  solid  residue  by  pressure." 

Dried  Fruits  can  be  eaten  less  abundantly  than  fresh  fruits. 
Some  of  the  dried  fruits  are  wholly  indigestible;  such  are  currants 
and  citrons.  Others,  like  figs  or  prunes,  are  wholesome,  and  raisins, 
sultanas,  dates,  etc.,  contain  considerable  nourishment.  All  these 
dried  fruits  are  preserved  in  their  own  sugar  (glucose),  which  forms 
a  sticky,  gummy,  non-crystallised  mass,  Dried  apples,  peaches, 
prunelles,  etc.,  are  preserved  simply  by  the  evaporation  of  the  excess 
of  water  which  they  contain. 

Dried  "currants"  are  the  berries  of  a  vine  cultivated  in  the 
Ionian  Islands.  According  to  Pavy,  the  word  currant  is  a  cor- 
ruption of  Corinth.  The  fruit  in  its  dried  state  is  wholly  indi- 
gestible. 

When  dried  fruits,  such  as  figs  or  dates,  have  become  too  hard 
they  may  be  softened  and  made  more  palatable  by  pouring  boiling 
water  over  them  and  allowing  them  to  soak  for  a  few  hours,  or  the 
fruit  may  be  put  into  cold  milk  and  brought  to  the  boiling  point 
over  the  fire.  This  method  will  soften  them  in  a  quarter  of  an 
hour. 

A  simple  fruit  diet  which  has  been  advocated  for  the  cure  of 
obesity  and  other  ailments  is  the  following:  Three  meals  a  day  are 
eaten,  consisting  of  half  a  pint  to  a  pint  of  milk,  with  from  two  to 
six  ounces  of  whole-meal  bread  and  a  similar  quantity  of  figs  or 
dates,  prepared  in  milk  as  above  described.  Obviously  this  diet  is 
not  sufficiently  sustaining  to  be  long  endured. 

Digestibility. — Among  the  commoner  fruits  of  easy  digestion 
are  grapes,  oranges,  lemons,  cooked  apples,  figs,  peaches,  strawber- 
ries, and  raspberries. 

Somewhat  less  digestible  are  melons,  prunes,  raw  apples,  pears, 
apricots,  bananas,  and  fresh  currants. 

Of  course  the  digestibility  depends  very  much  upon  ripeness  and 


VEGETABLE   FOODS.  l6l 

freshness  of  the  fruit  as  well  as  personal  idiosyncrasy,  and  any  classi- 
fication can  only  be  approximate. 

Fruits  most  Useful  for  Invalids. — The  most  useful  fruits  for  the 
sick  are  lemons,  oranges,  baked  apples,  stewed  prunes,  grapes,  banana 
meal  (not  the  fruit  pulp). 

Varieties  of  Fruits. — Lemons,  limes,  and  shaddocks  may  be  con- 
sidered together  as  possessing  the  same  general  properties.  Owing 
to  the  potash  and  other  salts  and  abundant  vegetable  acids  which 
they  contain,  they  are  the  most  serviceable  of  the  antiscorbutic  fruits, 
and  also  afford  an  agreeable  acid  and  pungent  flavour  to  articles  of 
diet  which  might  become  monotonous  in  taste.  For  many  persons 
the  addition  of  a  little  lemon  juice  to  some  articles  of  food,  such  as 
cooked  cereals  and  porridge  or  broiled  fish,  renders  them  more  im- 
mediately digestible,  and  it  can  be  regarded  as  having  almost  a 
specific  action  in  promoting  gastric  digestion,  although  it  is  difficult 
to  say  in  just  what  manner  this  comes  about.  Lemons  are  therefore 
a  most  desirable  addition  to  the  diet  kitchen. 

Lemon  juice  is  a  well-known  mild  remedy  for  seasickness,  and 
holding  a  thin  slice  of  freshly  cut  lemon  in  the  mouth  often  removes 
the  disagreeable  taste  from  a  coated  tongue,  cleanses  the  mouth,  and 
may  even  counteract  nausea.  Sour  lemonade  taken  in  moderation, 
and  made  quite  strong  by  squeezing  the  juice  of  one  or  two  lemons 
in  a  small  tumblerful  of  water,  with  the  addition  of  only  one  or  two 
lumps  of  sugar,  is  a  cooling  and  refreshing  drink  in  fevers,  and  does 
more  to  diminish  the  craving  of  thirst  than  almost  any  other  form 
of  beverage. 

For  those  who  fancy  effervescing  drinks,  the  lemonade  may  be 
improved  by  using  one  of  the  aerated  waters — such  as  Apollinaris, 
Vichy,  or  carbonic-acid  water — instead  of  plain  water,  or  efferves- 
cence may  be  produced  by  the  addition  of  five  or  ten  grains  of  sodi- 
um bicarbonate.  In  many  cases  this  mild  remedy  is  beneficial  to  the 
stomach. 

Henry  claims  that  pure  lemon  juice  poured  into  the  nose  will 
often  control  epistaxis. 

Limes. — The  lime  is  a  thin-skinned  acid  fruit,  but  there  is  also  a 
sweet  variety.  Although  less  extensively  eaten  throughout  this 
country  than  the  lemon,  which  it  resembles  in  effect,  it  is  equally 
serviceable,  and  nearly  ten  thousand  gallons  of  condensed  lime  juice 
are  imported  annually  into  this  country,  from  Jamaica.  To  make 
this  juice  the  fresh  limes  are  pressed  by  machinery,  and  the  seeds 
and  pulp  are  removed  by  straining  and  filtering.  The  juice  is  then 
boiled  down  to  a  high  degree  of  concentration.  It  is  carried  to 
prevent  scurvy  on  sailing  vessels,  and  used  in  almshouses  and  pris- 
ons, where  the  diet  is  monotonous. 

The  shaddock, pomelo,  or  citrus pomelanus,  is  a  very  large,  globular, 


l62  FOODS  AND  FOOD  PREPARATIONS, 

pulpy  fruit,  which  grows  in  clusters  on  pendant  branches.  The 
rind  is  thick  and  acid,  and  the  very  juicy  pulp  is  bitter.  The  fruit 
keeps  fresh  for  a  long  time.  It  is  coming  into  general  use  of  late, 
owing  to  improved  methods  of  cultivation,  although  it  is  still  a 
relatively  expensive  fruit  in  most  parts  of  the  country.  Many  per- 
sons find  that  half  a  shaddock  taken  at  the  commencement  of  break- 
fast has  both  a  laxative  and  diuretic  action,  and  it  is  always  cool- 
ing and  agreeable  to  those  who  do  not  dislike  a  bitter  taste.  The 
objection  to  its  use  is  that  it  requires  a  large  quantity  of  sugar  to 
make  it  really  palatable  and  diminish  its  astringency.  This  is  dis- 
advantageous in  cases  of  flatulent  dyspepsia,  but  for  invalids  who 
are  convalescing  from  prolonged  fevers,  suppurating  disease,  etc., 
an  excellent  tonic  may  be  given  by  cutting  a  shaddock  in  two  and 
pouring  half  an  ounce  or  more  of  good  rum  into  the  fruit,  with  the 
addition  of  a  little  sugar.  The  bitterness  is  entirely  disguised  and 
the  combination  is  agreeable  and  appetising. 

Oranges. — Oranges  are  an  exceedingly  useful  article  of  invalid 
diet.  The  juice  of  ripe  oranges  allays  thirst,  and  it  is  well  borne  in 
cases  where  there  is  considerable  gastric  irritation  and  tendency  to 
vomiting.  It  is  only  in  the  worst  forms  of  gastric  disorder  that 
orange  juice  disagrees,  and  there  is  no  fruit  which  is  so  generally 
available  in  the  sick-room,  for  it  is  agreeable  to  almost  every  one, 
and  is  soothing  and  refreshing  in  mild  fevers.  Orange  juice  is  laxa- 
tive, particularly  for  infants,  and  it  is  a  good  antiscorbutic.  It  may 
be  given  undiluted  or  made  into  orangeade  with  one  of  the  efferves- 
cing waters.  In  renal  and  other  diseases  in  which  it  is  desirable  to 
induce  the  patient  to  drink  large  quantities  of  fluid  for  its  diluent 
and  diuretic  effect,  the  addition  of  orange  juice  to  beverages  will 
often  encourage  their  consumption. 

Orange  marmalade  is  a  wholesome  relish,  having  an  appetising 
bitter  flavour. 

Orange  water  ice,  as  well  as  lemon  ice,  well  frozen,  if  not  made 
too  sweet,  may  be  allowed  in  the  milder  forms  of  fever,  inflammations 
of  the  throat,  etc.,  especially  in  children.  It  is  soothing,  refreshing, 
and  cooling,  and  is  less  apt  to  disagree  than  the  richer  ice  cream. 

Apples,  when  ripe  and  properly  selected,  are  extremely  wholesome 
and  very  digestible.  They  contain  abundant  potassium  and  sodium 
salts,  as  well  as  those  of  lime,  magnesium,  and  a  trace  of  iron.  Their 
nutritive  value  is  not  high,  depending  mainly  upon  a  little  sugar,  for 
they  are  largely  composed  of  water,  having  over  83.5  per  cent 
(Bauer).  In  dried  apples  the  percentage  of  water  is  reduced  to 
one  third,  while  that  of  sugar  is  proportionately  increased. 

Apples  contain  free  organic  acids  as  well  as  salts,  such  as  malates, 
citrates,  and  tartrates.  They  are  good  antiscorbutic  remedies,  and 
are  quite  laxative,  especially  when  taken  into   an   empty  stomach. 


VEGETABLE   FOODS. 


163 


There  are  many  dyspeptics  who  thrive  upon  apples,  even  if  eaten 
raw,  and  who  can  regulate  the  action  of  the  bowels  with  them  effec- 
tually. They  should  be  given  to  most  invalids  only  when  cooked. 
They  are  most  digestible  when  baked  and  eaten  with  cream,  or  they 
may  be  beaten  with  white  of  egg  to  add  to  their  nutritive  power. 
They  are  both  palatable  and  very  digestible  for  convalescents  if 
stewed  as  apple  sauce,  when  there  is  no  objection  to  the  addition  of 
the  greater  quantity  of  sugar  which  is  required  in  this  method  of 
cooking.  They  should  be  avoided  in  all  cases  of  diarrhoea,  gastro- 
intestinal irritation,  and  diabetes. 

Pears  are  similar  to  apples  in  their  effect,  but  are  less  laxative. 
If  fully  ripe  and  soft  they  are  even  more  digestible  raw  than 
apples.  They  have  the  advantage  of  keeping  their  flavour  when 
well  preserved  in  sirups,  but  they  possess  no  special  food  value, 
and  are  mainly  used  for  their  choice  flavour,  aroma,  and  appearance, 
which  stimulate  the  appetite. 

Quinces  are  indigestible  unless  very  thoroughly  cooked. 

Peaches,  nectarines,  and  apricots  are  of  comparatively  little  nutrient 
value,  but  their  flavour  and  appearance  make  them  tempting  articles 
for  the  table.  They  do  not  contain  as  much  sugar  as  apples  and 
other  fruits.  When  thoroughly  ripe  they  are  wholesome  if  not 
eaten  in  excess.  They  agree  well  with  some  gouty  persons,  and  are 
even  allowed  to  diabetics  in  cases  of  moderate  severity.  Peach  and 
apricot  juices  are  laxative  unless  the  fruits  are  very  ripe. 

Pineapples,  as  usually  obtained  in  this  country,  have  been  picked 
green  in  Cuba,  and  if  eaten  raw  are  indigestible.  Their  juice  is, 
however,  very  wholesome,  and  they  contain  a  ferment  capable  of 
digesting  proteid  material,  which  is  used  to  some  extent  in  the  pre- 
paration of  predigested  invalid  foods. 

Tamarinds  are  cooling  and  laxative.  When  added  to  milk  they 
cause  curdling  and  form  a  whey  which  may  be  used  as  a  beverage  in 
fevers  when  constipation  is  to  be  overcome. 

The  mango  is  a  sweet  and  somewhat  acid  fruit,  with  moderately 
laxative  action. 

The  pomegranate  is  a  pulpy  fruit,  wholesome  when  fresh,  but  it  is 
expensive  and  little  used  in  this  country.  It  has  a  thick,  tough  rind, 
which  is  astringent,  with  a  bitter-sweetish  taste.  A  taeniacide  for 
the  tapeworm  is  made  from  an  infusion  of  the  rind,  but  it  is  so 
nauseous  and  disgusting  to  the  taste  that  patients  can  seldom  retain 
it  unless  it  is  put  into  the  stomach  with  a  tube. 

Bananas. — The  banana  is  really  a  variety  of  the  plantain,  or  Plan- 
tago  musa,  but  the  fruit  is  not  so  large  or  so  hard  as  that  commonly 
called  plantain,  and  the  flavour  is  far  more  delicate.  The  botanical 
name  of  the  banana,  Musa  sapientum,  was  given  because  it  constituted 
the   principal    food    of    the    Brahmin    caste   of    India.      There   are 


164  FOODS  AND  FOOD  PREPARATIONS. 

many  score  of  varieties  of  the  banana,  ranging  from  the  most 
delicate  examples  of  the  Miisa  sapientum  family  to  the  heaviest  of 
the  plantains,  and  they  vary  in  digestibility  as  they  do  in  flavour. 
Casati  (Equatorial  Province,  1891)  names  some  fourteen  varieties, 
having  different  characteristics  and  occurring  in  the  Equatorial 
Province  of  Africa  alone.  He  noted  that,  curiously,  only  the  women 
and  children  ate  the  natural  fruit,  the  warriors  feeding  on  the  fruits 
dried  and  prepared  in  oil — probably  from  an  intuition  that  they  were 
more  highly  nourished  by  the  concentrated  food. 

In  the  West  Indies,  in  the  islands  of  the  Pacific,  along  the  Congo, 
and  throughout  Central  Africa  many  natives  eat  bananas  as  their 
staple  article  of  food,  and  maintain  good  physical  development.  The 
fact  that  a  diet  consisting  solely  of  this  fruit  will  sustain  life  for  long 
periods  is  owing  to  the  relatively  high  percentage  of  nitrogen  which 
it  contains  compared  with  sago,  arrowroot,  and  similar  carbohydrates. 
This  percentage  amounts  to  nearly  five  parts  per  hundred  of  the  en- 
tire fruit,  or  one  fifth  of  the  total  solids  (Corenwinder). 

Grown  on  a  given  acreage,  bananas  will  support  a  larger  number 
of  persons  than  wheat. 

The  banana  has  of  late  years  assumed  a  very  important  position 
among  fruits  sold  in  this  country.  Improvements  in  cultivation  and 
means  of  transportation,  and  the  length  of  time  through  which  the 
ifruit  will  keep  without  spoiling,  are  accountable  for  this,  and  up- 
wards of  one  hundred  thousand  bunches  of  bananas  are  sold  per 
:month  for  distribution  in  New  York  city  and  vicinity  alone.  It 
.ranks  equally  with  the  orange  in  extent  of  consumption,  and  during 
the  winter  months  it  is  often  the  only  fresh  fruit  which  is  universally 
obtainable  in  remote  country  districts,  while  its  cheapness  places  it 
within  the  reach  of  almost  every  one. 

In  British  Guiana  the  banana  is  employed  especially  as  a  nourish- 
ing food  for  young  children  and  invalids. 

Many  persons  find  that  they  cannot  easily  digest  bananas  as  we 
obtain  them  in  this  country ;  but  this  no  doubt  depends  upon  the  fact 
that  the  fruit  shipped  to  the  United  States  is  picked  very  green,  and 
is  often  quite  immature  and  irregularly  ripened  when  eaten.  Imper- 
fectly ripened  bananas  are  composed  chiefly  of  starch,  but,  as  the 
natural  ripening  proceeds,  the  saccharine  material  is  converted  into 
a  mucilaginous  substance,  which  in  turn  forms  dextrin  and  glucose. 

The  flour,  which  is  made  by  drying  carefully  selected  and  well- 
ripened  bananas,  is,  however,  remarkably  easy  to  digest,  and  highly 
nutritious. 

Surgeon  Parke  (My  Personal  Experience  in  Equatorial  Africa, 
p.  416),  in  an  instructive  and  interesting  account  of  his  experience 
with  the  sick  of  the  Emin  Pasha  Relief  Expedition,  refers  to  Mr. 
Stanley,  who  was  in  the  midst  of  a  severe  attack  of  acute  gastritis, 


VEGETABLE   FOODS. 


165 


as  follows:  "  He  eats  porridge  made  with  banana  flour  and  milk.  It 
is  very  light  and  digestible,  and  has  more  flavour  than  arrowroot;  it 
is  also  very  nutritious.  We  whites  have  very  good  reason  to  know 
this  fact  now,  as  we  have  mostly  lived  on  banana  flour  for  the  past 
two  years." 

During  most  of  this  period,  it  should  be  observed,  the  members 
of  the  expedition  were  taking  very  long  marches  and  were  suffering 
from  frequent  attacks  of  malarial  fever,  which  were  a  severe  test  of 
the  nutritive  qualities  of  any  dietary. 

Farinaceous  food  is  so  prone  to  undergo  malfermentation  in  the 
stomach  when  the  normal  digestion  is  disordered  that  it  becomes 
very  important  to  seek  some  variety  of  starchy  food  which  can  be 
easily  assimilated  without  the  production  of  acid  eructations,  flatu- 
lence, or  heartburn.  The  starchy  foods  which  have  heretofore  been 
obtainable  in  this  country  for  this  purpose  have  been  all  derived 
from  tubers  or  cereals  which  have  been  rendered  more  assimilable  by 
predigestion  or  "malting." 

It  is  difficult  to  make  a  good  fruit  flour,  for  many  fruits,  when 
dried,  form  a  mucilaginous  mass  like  the  fig,  or  a  sticky  material  like 
the  raisin,  or  shrivel  to  a  stringy  substance  like  the  apple  and  the 
apricot.  But  the  banana,  in  some  varieties  and  conditions,  consti- 
tutes an  important  exception,  and  when  carefully  selected  and  thor- 
oughly dried  it  can  be  ground  into  a  meal  or  even  into  a  flour, 
making  as  fine  a  powder  as  arrowroot,  having  a  white  or  pale  greyish 
or  yellowish  colour,  and  an  agreeable  faintly  aromatic  odour  and 
taste. 

This  meal  possesses  decided  intrinsic  advantages  as  an  invalid 
food.  I  have  tested  these  preparations,  both  experimentally  in  the 
laboratory  and  clinically,  and  found  that  an  unboiled  saturated 
aqueous  solution  of  banana  flour  contains  a  very  large  percentage  of 
sugar — from  one  half  to  three  fourths  as  much  as  certain  of  the  best 
known  prepared  saccharine  foods  for  infants  to  which  sugar  had 
been  artificially  added.  The  finest  banana  flour,  called  "bananose," 
at  the  end  of  one  and  a  half  hour  of  pancreatic  digestion  was 
capable  of  developing  twice  as  much  sugar  as  the  same  quantity  of 
oatmeal  or  farina,  and  approximately  one  and  a  half  time  as  much 
sugar  as  cornstarch.  Saliva,  when  substituted  for  pancreatic  ex- 
tract, produces  a  similar  effect. 

The  banana  flour,  when  prepared  from  the  best  quality  of  bananas, 
is  made  into  a  thin  gruel  or  porridge  by  the  addition  of  either  water 
or  milk,  and  eaten  with  cream  it  constitutes  a  delicious  and  highly 
nutritious  article  of  diet  suitable  in  cases  of  gastric  irritability  and 
acute  gastritis,  etc.  It  is  particularly  serviceable  for  children  be- 
tween five  and  ten  years  of  age.  For  those  craving  an  acid  flavour, 
lemon  juice  with  powdered  sugar  upon  the  banana  porridge  is  found 


1 66  FOODS  AND  FOOD  PREPARATIONS. 

to  be  very  acceptable.  The  records  of  some  fifty  cases  in  the  New 
York  and  Presbyterian  Hospitals  to  which  I  gave  gruel  or  porridge 
made  with  banana  flour  show  that  it  was  exceptionally  well  borne  by 
irritable  stomachs,  almost  never  vomited,  having  no  tendency  to  pro- 
duce acidity  from  flatulence,  nor  did  it  cause  diarrhoea  or  any  ap- 
parent laxative  effect.  It  proved  very  useful  in  several  cases  of  sim- 
ple gastritis  and  acute  gastritis  complicating  chronic  indigestion  and 
in  the  early  convalescent  stage  of  typhoid  fever.  It  was  used  with 
advantage  even  during  the  fever  itself  whenever  a  change  from  an 
exclusive  milk  diet  seemed  indicated  either  by  the  patient's  dislike 
for  milk  or  by  its  causing  dyspepsia. 

The  taste  of  banana  flour  is  peculiar,  and  is  not  always  agreeable 
at  first ;  but  it  may  be  so  modified  by  different  processes  of  cooking 
that  the  majority  of  patients  find  it  much  more  palatable  than  the 
conventional  arrowroot,  cornstarch,  or  farina.  It  is  a  decided  gain 
to  be  able  to  enlarge  the  list  of  starchy  foods  adapted  to  feeble 
digestions  by  a  fruit  flour  which  presents  the  following  advantages  : 
An  agreeable  variety  of  taste  ;  a  high  percentage  of  nitrogen,  dex- 
trin, and  glucose;  ready  digestibility;  high  nutritive  value;  the  prop- 
erty of  keeping  definitely  in  a  concentrated  dry  state,  ready  for  im- 
mediate use. 

Grapes. — Grapes  are  universally  grown  and  enjoyed  on  account 
of  their  delicious  flavour  and  aroma  as  well  as  their  general  whole- 
someness,  and  they  constitute  an  important  article  of  diet.  Per- 
fectly ripe  and  seedless  grapes,  such  as  the  Black  Hamburg  and 
other  varieties,  have  long  been  recognised  as  an  excellent  food  for 
invalids.  Grapes  contain  so  large  a  proportion  of  water  that  they 
possess  but  little  nutrient  property,  although  they  hold  considerable 
sugar,  but  the  salts  which  they  furnish  to  the  system  are  useful. 

The  habit  which  some  people  have  of  swallowing  the  pulp  whole 
with  the  seeds,  however  small  the  latter  may  be,  cannot  be  too 
strongly  condemned.  The  seeds  under  no  circumstances  are  digested, 
being  too  hard  and  tough  to  be  affected  by  any  of  the  juices  of  the 
digestive  tract,  and  they  therefore  act  as  irritants  or  foreign  bodies. 
It  was  originally  believed  that  inflammation  of  the  appendix  vermi- 
formis  was  often  caused  by  the  entrance  of  one  or  two  sharp-pointed 
grape  seeds  into  this  small  division  of  the  alimentary  canal,  and  in 
exceptional  cases  no  doubt  this  may  occur;  but  the  disease  is  far 
too  common  among  those  who  have  not  eaten  grapes  to  assign 
much  importance  to  such  a  theory.  The  main  disadvantage  of  swal- 
lowing seeds  consists  in  their  interference  with  normal  digestive 
processes,  while  they  are  liable  at  any  time  to  cause  more  serious 
disturbance  of  the  nature  of  diarrhoea,  enteritis,  or  intestinal  obstruc- 
tion.    Swallowing  the  skins  of  grapes  is  equally  harmful. 

Grapes,  on  account  of  their  sugar,  must  be  forbidden  in  cases  of 


VEGETABLE  FOODS.  1 67 

diabetes  and  gout.  A  special  "  grape  cure  "  has  been  established  for 
some  diseases.  It  is  discussed  under  that  heading.  Unfermented 
California  grape  juice  constitutes  an  agreeable,  wholesome,  and 
slightly  laxative,  non-alcoholic  beverage,  which  may  be  prescribed 
during  mild  fevers  and  in  convalescence. 

Raisins,  prepared  by  sun  drying  from  certain  species  of  grapes 
which  are  particularly  rich  in  sugar,  form  a  useful  food,  chiefly  oh 
account  of  the  agreeable  flavour  which  they  impart  to  more  insipid 
substances  (see  also  Raisin  Wine).  * 

Raisins  are  usually  made  from  white  grapes,  but  they  turn  dark 
purple  or  brown  from  oxidation  of  the  tannic  acid  of  their  skins 
(Leoser).  Muscatel  raisins  are  dried  on  the  vine  by  incising  the 
stems  to  cause  withering  of  the  grapes. 

Raisins  cannot  be  eaten  very  abundantly  without  disordering 
digestion  unless  they  have  been  cooked.  Added  to  some  forms  of 
farinaceous  food — such  as  rice  pudding,  sweetened  breads,  buns, 
cakes,  pemmican,  and  the  like — they  increase  the  appetite.  If  given 
to  children,  as  they  too  often  are,  they  should  be  stoned  carefully 
beforehand,  and  the  tough  skins  must  not  be  swallowed.  The  latter 
contain  a  whitish  waxy  material  which  keeps  the  grapes  waterproof. 

Plums. — Plums  and  green  gages  are  wholesome  fruits  when  they 
are  wholly  ripe;  but  they  remain  fresh  for  only  a  short  time,  and  are 
often  on  that  account  picked  and  sent  to  market  in  an  unripe  condi- 
tion, in  which  they  are  very  indigestible,  and  are  particularly  apt  to 
excite  diarrhoea  and  intestinal  colic. 

Prunes. — Prunes  or  dried  plums  are  obtainable  in  various  forms 
and  sold  in  large  masses  like  dates,  or  preserved  individually  in  jars, 
in  which  form  they  have  the  advantage  of  keeping  well  for  a  long 
period.  They  contain  a  large  percentage  of  sugar.  They  have  a  dis- 
tinctly laxative  effect,  eaten  raw  or,  preferably,  stewed,  and  they  are 
very  wholesome  and  useful  in  cases  of  chronic  constipation.  They 
are  comparatively  inexpensive,  and  by  some  patients  may  be  taken 
two  or  three  times  a  day.  They  have  a  good  effect  in  regulating  the 
bowels  in  children,  and  three  or  four  prunes  given  once  or  twice  a 
day  between  meals  will  sometimes  prove  quite  sufficient  for  this 
purpose. 

Ptunelles  are  sold  in  masses  dried  like  dates.  They  have  a  pleas- 
ant acid  flavour,  but  are  not  very  digestible. 

Olives  are  eaten  for  their  agreeable  flavour  and  their  nutrient 
value,  which  is  due  to  the  oil  they  contain  (see  Olive  Oil).  They 
may  be  eaten  fresh  in  the  warm  countries  where  they  grow,  but  they 
are  too  bitter  for  most  palates,  and  are  usually  preserved  by  soaking 
respectively  in  {a)  strong  lye,  {b)  fresh  water,  and  {c)  salt  solution, 
and  are  left  in  the  latter  for  preservation.  The  lye  neutralises  their 
bitter  taste. 


1 68  FOODS  AND  FOOD  PREPARATIONS. 

Berries. — The  straiuberry,  on  account  of  its  exceptional!}'  agree- 
able flavour,  and  also  from  the  fact  that  it  is  one  of  the  first  fruits  of 
the  spring  season  in  the  eastern  part  of  this  country,  is  enjoyed  by 
almost  every  one.  There  are,  however,  a  few  persons  who  have  a 
striking  idiosyncrasy  against  it,  and  in  whom  urticaria  or  more  or 
less  violent  gastro-enteritis  with  sore  throat  (Osier)  is  promptly 
developed  by  taking  even  a  few  berries.  The  reason  for  this  is  not 
fully  explained,  for  analysis  of  the  strawberry  fails  to  show  any 
product  which  is  peculiar  to  itself.  There  must  consequently  be 
some  combination  of  organic  acids  or  other  materials  existing  in 
this  berry  which  is  exceptionally  irritating  to  some  persons. 

The  strawberry  is  usually  a  very  wholesome  food.  It  contains 
abundant  salts  of  potash,  lime,  and  soda,  which  give  it  a  moderate 
diuretic  action ;  it  is  also  slightly  laxative,  partly  from  the  seeds 
which  it  contains.  There  are  many  modes  of  eating,  cooking,  and 
preserving  the  strawberry  which  are  too  familiar  to  require  comment 
here.  Some  persons  learn  that  eating  the  berry  with  pepper  or  lemon 
juice  enables  them  to  digest  it  better,  and  those  who  suffer  from 
flatulent  dyspepsia,  if  they  can  digest  the  berry  at  all,  do  well  to  take 
it  without  sugar. 

Currants,  bilberries,  mulberries,  blueberries,  huckleberries,  raspberries, 
blackberries,  and  gooseberries  all  contain  considerable  free  acid,  and 
are  moderately  laxative,  partly  on  account  of  their  seeds,  but  their 
expressed  juices  sometimes  have  the  same  effect.  Not  all  berries 
are  laxative,  however.  Huckleberries  and  blueberries  may  be  laxa- 
tive when  eaten  with  their  seeds  and  skins,  but  Winternitz  has  re- 
cently shown  that  a  decoction  made  from  these  berries  is  a  good 
astringent  for  use  in  chronic  diarrhoea.  Blackberries  have  a  similar 
action. 

The  expressed  juice  of  red  currants,  raspberries,  or  blackberries 
makes  a  cooling  and  refreshing  beverage  or  "  shrub  "  when  added  to 
some  effervescing  water,  such  as  Apollinaris  or  carbonic-acid  water, 
and  may  sometimes  be  used  in  fevers,  although  lemon  juice  is  usually 
preferable. 

Currants  are  preserved  in  various  ways,  the  chief  one  being  in 
the  form  of  jelly.  Prepared  in  this  manner,  they  constitute  an  appe- 
tising and  wholesome  flavouring  material,  which  may  be  taken  with 
meats  and  other  foods  to  excite  the  appetite  of  invalids  and  con- 
valescents whose  chief  difficulty  is  lack  of  desire  for  sufficient  food. 

Currants,  raspberries,  blackberries,  etc.,  are  frequently  made  into 
jams.  These,  on  account  of  the  large  quantity  of  sugar  which  is 
added  in  their  preparation,  are  quite  nutritious,  and  their  numerous 
seeds  have  a  laxative  action.  For  this  purpose  they  are  sometimes 
beneficially  given  to  children  to  be  eaten  with  bread  and  butter. 
They  aid   in   satisfying  the  natural  craving  of  children  for  sweets. 


VEGETABLE   FOODS. 


169 


and,  if  taken  in  moderation,  they  are  very  wholesome,  and  their  taste 
may  encourage  the  eating  of  more  nutritious  but  less  agreeably 
flavoured  food,  such  as  rice,  cornstarch,  or  farina. 

The  gooseberry  is  much  more  popular  in  England  than  in  the 
United  States.  It  contains  citric  and  malic  acids  as  well  as  sugar. 
It  is  rendered  more  wholesome  by  cooking,  and  is  sometimes  made 
into  wine. 

The  elderberry  furnishes  an  astringent  wine,  which  is  also  some- 
what diuretic  and  sudorific. 

Melons. — Melons  are  of  little  service  for  nutrition,  but  they  are 
so  agreeable  to  the  palate  that  they  are  in  very  general  use.  The 
varieties  commonly  obtainable  in  this  country  are  the  cantaloupe,  or 
muskmelon,  and  watermelon,  and  of  these,  the  former  is  less  apt  to 
produce  gastro-intestinal  disorder  when  not  eaten  too  freely. 

These  fruits  contain  so  large  a  proportion  of  water — upward  of 
95  per  cent — that  they  are  not  satisfying  to  the  appetite ;  and  since 
in  hot  weather  they  are  cool  and  refreshing,  overindulgence  in  them 
is  a  common  fault,  and  most  of  the  ill  repute  of  watermelons  has 
arisen  in  this  way  rather  than  from  any  specific  injurious  effect  which 
they  produce.  If  eaten  with  other  food,  they  dilute  the  gastric 
juice.  Well-ripened  muskmelons  may  often  be  eaten  by  invalids  in 
moderation  to  promote  the  appetite,  served  at  the  commencement  of 
a  meal,  at  which  time  it  is  best  that  most  fruit  should  be  eaten  when 
taken  with  other  food. 

Citrons  are  very  indigestible. 

Figs  and  Dates. — Figs  and  dates  are  chiefly  eaten  in  the  United 
States  in  the  dry  form,  although  in  California  and  elsewhere  they 
may  be  obtained  fresh.  These  fruits  hold  large  quantities  of 
sugar,  especially  in  their  dry  state,  in  which  this  ingredient  is  not 
only  concentrated,  but  changed  in  the  drying  process.  They  also 
contain  a  little  nitrogenous  material,  so  that  they  have  more  nutri- 
tive value  than  many  fruits;  in  fact,  in  some  countries  they  consti- 
tute a  staple  article  of  diet.  This  applies  to  the  use  of  the  date  in 
Arabia. 

Figs  have  a  decided  aperient  action,  which  is  chiefly,  but  not 
solely,  owing  to  their  seeds.  Three  or  four  dried  figs  taken  with  a 
glassful  of  water  at  night  before  retiring,  and  again  half  an  hour  be- 
fore breakfast,  will  sometimes  cure  mild  constipation.  The  dried 
figs,  like  prunes,  may  be  stewed  if  preferred.  They  contain  a  large 
percentage  of  glucose.  The  best  figs,  called  Turkey  figs,  are  raised 
in  Smyrna,  and  when  dried  will  keep  for  a  long  time. 

Fungi. 

There  are  many  species  of  fungi,  some  of  which  are  available  for 
food,  while  others   are  irritating,  and  still   others  produce  violent 


■i/o 


FOODS   AND   FOOD  PREPARATIONS. 


gastro-intestinal  disorder,  and  by  their  absorption  give  rise  tO  symp- 
toms of  collapse,  and  may  cause  death. 

Konig  gives  the  following  percentage  composition  : 


Water 

Non-nitrogenous  substances 

Fat 

Grape  sugar,  mannite 

Other  non-nitrogenous  substances. 

Woody  fibre 

Ash 


Fresh  mushroom. 


91. II 

2.57 
0.13 
1.05 

3-71 
0.67 
0.76 


Fresh  truffle. 


72.08 
8.91 
,0.62 

7-54 
7.92 
2.21 


Fresh  common 
morel. 


90.00 
3-48 
0.24 
0.72 

3-95 
0.67 
0.94 


Mushrooms. — Mushrooms,  on  account  of  their  nitrogenous  matter, 
are  of  some  slight  use  as  food ;  but  if  eaten  in  sufficient  quantity  to 
yield  much  nutriment,  they  always  disagree.  Bauer  says :  "  Judg- 
ing from  their  chemical  composition,  they  ought  to  have  no  small 
value  as  foods,  but  it  is  doubtful  how  far  they  are  really  utilised  in 
the  alimentary  canal." 

Mushrooms  have  a  tempting  flavour,  which  is  developed  on  cook- 
ing, and  while  they  agree  with  most  persons  in  health  and  form  an 
acceptable  article  of  diet,  there  are  some  persons  who  can  never 
eat  even  the  simplest  varieties  without  suffering  more  or  less  from 
acute  gastro-intestinal  irritation.  They  should  never  be  eaten  raw. 
They  are  usually  served  alone,  broiled  upon  toast  or  as  a  dressing 
for  beef,  fillet,  steak,  etc.,  or  they  may  be  preserved  in  olive  oil  or 
by  drying. 

Truffles. — The  truffle  is  a  subterranean  vegetable  of  the  order  of 
Thecapore.  It  is  an  expensive  luxury,  and  is  used  to  add  flavour  in 
cooking  and  as  an  ingredient  of  rich  meat  sauces, /i/'/.y,  etc.  It  con- 
tains no  sugar.  Eaten  in  quantity  by  itself  it  is  a  highly  indigestible 
substance.  It  easily  decomposes  with  a  very  offensive  nauseous 
odour.  There  are  several  varieties,  of  which  the  black  is  the  chief, 
and  it  is  obtained  from  beneath  the  trees  of  oak  forests  of  Perigord 
in  Southern  France,  where  it  is  hunted  by  trained  Spanish  poodles  or 
sows,  whose  sense  of  smell  enables  them  to  detect  the  fungus  beneath 
the  ground.  There  is  a  special  hereditary  race  of  trufiling  swine, 
broken  for  the  purpose. 

The  morel  is  a  friable,  greyish-black,  cone-shaped  mushroom, 
which  grows  extensively  in  a  variety  of  dry  soils,  but,  like  the  cepe,  is 
obtained  principally  in  France.  It  may  be  cultivated  artificially.  It 
is  used  for  flavouring,  like  the  truffle. 

Clpe  is  a  name  given  to  several  mushrooms  belonging  to  the 
Boletus  family,  which  are  globular  in  shape,  and  coloured  orange  or 
white. 


VEGETABLE  FOODS. 


171 


Poisonous  Fungi. — Most  poisonous  fungi  are  distinguished 
from  the  non-poisonous  by  a  warty  cap.  They  are  acrid  or  astrin- 
gent, and  have  a  pungent,  disagreeable  odour  (Christison). 

Muscarin  is  a  substance  isolated  from  poisonous  fungi,  which  is  a 
violent  cardiac  poison  and  constrictor  of  the  pulmonary  blood  vessels, 
producing  dyspnoea,  prostration,  and  death.  Its  effects  are  opposed 
to  those  of  belladonna. 

Lichen. 

Iceland  moss  is  used  extensively  as  a  food  by  dwellers  in  the 
arctic  regions. 

Konig  gives  the  percentage  composition  of  the  dried  moss  as  fol- 
lows: Water,  15.96;  nitrogenous  matter,  2.19;  fat,  1.41  ;  non-nitro- 
genous matter,  76.12. 

A  bread  is  made  from  it  after  carefully  washing  out  two  bitter 
organic  acids  which  it  contains.  Senator  has  recommended  this 
bread  for  use  by  diabetics. 

Nuts. 

Nuts  contain  proteids,  with  some  starch  and  more  or  less  fat. 
With  the  exception  of  the  cocoanut,  chestnut,  almond,  and  English 
walnut,  the  varieties  eaten  in  this  country  furnish  but  little  nutri- 
ment. Their  chief  value  is  to  stimulate  the  appetite  and  afford 
variety  in  the  diet.  As  a  rule,  they  are  to  be  proscribed  from  in- 
valid dietaries,  but,  with-'the  exception  of  chestnuts  and  peanuts, 
they  may  be  allowed  to  diabetics,  and  there  are  some  few  patients 
with  dyspepsia  whose  sluggish  stomachs  are  stimulated  into  greater 
activity  by  eating  a  few  parched  or  salted  almonds  or  walnuts  after 
a  meal. 

Almonds  contain  a  ferment  called  emulsin  and  much  fat,  and 
sweet  almonds  have  3  to  5  per  cent  of  sugar,  but  no  starch  (Bauer). 
This  low  percentage  of  sugar  makes  them  of  service  in  the  treatment 
of  diabetes,  in  which  disease  they  are  sometimes  used  as  a  substitute 
for  bread  after  being  ground  into  meal  (see  Diabetic  Breads,  p.  653). 

Macaroons  are  a  digestible  form  of  cake  for  convalescents  and 
children  composed  chiefly  of  almonds  and  sugar. 

Almonds  are  quite  wholesome  and  nutritious.  They  should  not 
be  eaten  in  cases  of  gastric  irritability,  but  occasoinally  dyspeptics 
in  whom  gastric  digestion  is  slow  derive  benefit  from  eating  a  few 
salted  almonds  with  meals.  They  should  be  soaked  and  peeled  or 
"blanched,"  otherwise  their  skins  may  set  up  gastric  irritation. 

The  bitter  almond  contains  hydrocyanic  acid,  sugar,  and  oil,  and 
is  not  used  except  for  flavouring  cough  mixtures. 

English  walnuts  eaten  liberally  between  meals  may  assist  in  over- 
coming constipation  through  the  bulk  of  insoluble  residue  which 
they  leave. 


172 


FOODS  AND  FOOD  PREPARATIONS. 


Cocoanuts  are  very  indigestible  even  when  thoroughly  desiccated 
and  grated.  The  cocoanut  contains  a  proteolytic  ferment  which  con- 
verts meat  into  albumoses  with  considerable  activity. 

Brazil  nuts,  pecan  nuts,  butternuts,  filberts,  etc.,  all  hold  much  oil, 
and  are  difficult  of  digestion. 

Chestnuts  contain  15  per  cent  of  sugar  with  so  much  starch  that 
they  are  very  nutritious,  and  in  some  parts  of  Italy  they  are  made 
into  cakes  and  eaten  by  the  peasants  as  a  substitute  for  potatoes. 
Raw  chestnuts  are  wholly  indigestible,  but  if  thoroughly  roasted  or, 
better  still,  if  long  boiled,  they  become  much  less  so.  They  should, 
however,  not  be  given  to  invalids. 

Peanuts  are  nutritious,  but  indigestible  when  roasted  whole.  Pea- 
nut flour  is  made  from  the  ground  and  bolted  nuts,  and  it  is  claimed 
that  a  pound  of  it  contains  as  much  nutritive  material  as  three  pounds 
of  beef  or  two  of  peas.  The  peanut  grits  may  be  boiled  like  oatmeal 
or  made  into  biscuits.  Experiments  have  lately  been  made  with  the 
view  of  possible  introduction  of  this  food  into  the  German  army  to 
be  used  like  the  *^  Erbswurst"  of  fame  in  the  Franco-Prussian  War. 
Peanuts  contain  considerable  oil,  which  is  extracted  and  sold  largely 
as  spurious  olive  oil.  It  is  also  sometimes  used  in  the  preparation  of 
oleomargarine,  and  the  roasted  nuts  themselves  make  a  sort  of  imita- 
tion coffee.  A  form  of  peanut  meal  is  now  prepared  for  diabetics 
which  is  said  to  contain  little  or  no  carbohydrate. 

V.   FATS  AND  OILS. 

Fats  and  oils  contain  but  three  elements — namely,  carbon,  oxy- 
gen, and  hydrogen.  In  the  starches  and  sugars  the  proportion  of 
oxygen  and  hydrogen  is  such  as  to  form  water,  HgO,  when  their 
molecules  are  split  up;  but  in  the  group  of  fats  oxygen  is  not 
present  in  sufficient  quantity  to  form  water  with  all  the  hydrogen 
atoms,  and  in  their  combustion  with  oxygen  considerable  heat  is 
evolved.  In  some  fats,  like  butter,  but  very  little  oxygen  is  pres- 
ent, and  carbon  and  hydrogen  compose  the  bulk  of  the  substance. 
The  amount  of  fat  which  from  time  to  time  is  stored  in  the  body  is 
regulated  to  a  greater  degree  than  any  other  substance  by  muscular 
exercise,  which,  if  active,  always  tends  to  prevent  its  accumulation. 
The  storage  of  fat  is  favoured  by  sleep  as  well  as  inactivity  (see 
Obesity  and  Leanness,  pages  599  and  615). 

About  one  fifth  of  the  entire  body  weight  is  composed  of  fat, 
but  only  about  a  quarter  of  an  ounce  is  contained  in  the  blood. 
Before  death  results  from  starvation  90  per  cent  of  the  body  fat  is 
consumed.  The  chief  sources  of  this  fat  in  the  human  body  are 
undoubtedly  starches  and  sugars,  but  it  is  probable  that  under  cer- 
tain conditions  it  may  also  be  derived  from  fatty  food. 


PLATE  IX. 


Beef  Fat  x  40. 


Oleomargarine  x  40. 


ANIMAL    FATS,    MAGNIFIED. 
f<}-om  liulUim  No.  IS,  IHmmm  of  Chemislrif,  Vmled  SUiU-k  AgrimUurdl  Jiamiu). 


P'riOTO     B^    I  I,IKKciKl>   UK  IIAItllSliN. 


FATS   AND   OILS. 


173 


Fat  is  required  to  promote  the  earlier  stages  of  growth  and  de- 
velopment of  the  organism,  and  there  are  also  many  forms  of  disease 
and  degenerative  changes  which  are  accompanied  by  increased  accu- 
mulation or  production  of  fat  in  and  between  the  tissues  and  cells. 
It  is  impossible  to  live  in  perfect  health  without  fatty  food,  and  it  is 
equally  impossible  to  live  long  upon  fat  alone,  for  it  soon  disorders 
the  digestion  and  causes  absolute  disgust. 

Fat  constitutes  one  of  the  ingredients  of  pus,  and  is  found  in  the 
normal  living  white  blood-corpuscles,  and  after  the  ingestion  of  fat 
in  excess  as  food,  a  sufficient  quantity  of  it  may  be  absorbed  into 
the  serum  of  the  blood  to  give  rise  to  a  thin  film  upon  its  surface 
when  shed. 

In  hot  climates  where  fat  meats  are  scarce,  or  their  use  is  pro- 
hibited by  the  religion  of  the  inhabitants,  they  employ  the  oils  of 
fish,  vegetables,  or  fruits  instead. 

Uses  of  Fats. — The  chief  uses  of  fatty  food  are  : 

1.  To  furnish  energy  for  the  development  of  heat. 

2.  To  supply  force. 

3.  To  serve  as  covering  and  protection  in  the  body. 

4.  To  lubricate  and  make  more  plastic  various  structures  of  the 
body  and  give  rotundity  to  the  form. 

5.  To  spare  the  tissues  from  disintegration,  for,  although  their 
combustion  in  the  body  results  largely  in  the  production  of  heat, 
they  also  take  part  to  some  extent  in  tissue  formation. 

6.  To  serve  for  storage  of  energy. 

The  various  forms  of  energy  manifested  in  the  different  nitro- 
genous tissues — as  muscular  action,  secretion,  nerve  force,  etc — are 
more  or  less  intimately  dependent  upon  fat  combustion.  It  was 
originally  believed  that  the  force  of  the  body  was  supplied  by  the 
oxidation  of  nitrogenous  materials.  Fat  eaten  with  the  food  was 
supposed  to  be  deposited  again  as  fat  in  the  tissues  of  the  body 
without  material  change,  but  of  recent  years  this  theory  has  been 
very  largely  recast,  and  the  primary  value  of  fatty  food  exists  un- 
doubtedly in  its  contribution  to  force  production  and  its  power  of 
saving  other  tissues,  especially  the  albuminous,  from  destruction  by 
oxidation,  whereas  its  secondary  use  is  in  connection  with  tissue 
formation.  Fats  do,  however,  enter  into  the  composition  of  many 
different  tissues,  even  those  of  the  nervous  system. 

The  fats  and  oils  which  are  employed  as  food  all  serve  essen- 
tially the  same  purpose,  and  may  therefore  be  grouped  together  as 
a  distinct  class.  There  is  a  general  resemblance  in  their  physical 
properties,  although  they  differ  considerably  in  the  melting  point. 
The  several  food  fats  and  oils  are  of  various  chemical  composition, 
but  after  being  absorbed  they  are  recognised  mainly  in  one  or  two 
simple  forms,  chiefly  as  stearin  and  olein. 


J74 


FOODS   AND   FOOD   PREPARATIONS. 


The  use  of  animal  oils,  such  as  lanolin,  and  of  the  petroleum 
products,  like  purified  vaseline,  has  very  largely  superseded  the  ex' 
ternal  application  of  other  fatty  substances — lard,  etc. — to  the  skin 
for  the  purpose  of  lubrication. 

It  is  not  possible  to  get  very  much  nourishment  into  the  body 
by  osmosis  through  the  integument,  but  some  improvement  seems  to 
follow  the  rubbing  of  fats  and  oils,  such  as  cacao  butter,  olive  oil,  or 
cod-liver  oil  through  the  skin  of  marasmic  children  and  other  pa- 
tients (see  Marasmus).  One  or  two  teaspoonfuls  of  the  oil  may  be 
rubbed  in  twice  a  day  on  the  thighs,  abdomen,  and  chest.  The  state- 
ment that  the  application  of  fats  to  the  surface  of  the  body  by 
inunction  reduces  the  body  temperature  is  not  substantiated  by 
experience. 

The  treatment  of  biliary  calculi  by  the  administration  of  large 
doses  of  olive  oil — two  or  three  ounces  at  a  time — given  upoi;i  an 
empty  stomach,  has  been  suggested,  apparently  with  the  idea  that  it 
might  have  some  local  lubricating  action.  Cases  have  been  reported 
in  which  gallstones  have  been  said  to  appear  in  the  f?eces  as  a  result 
of  this  treatment,  but  it  has  been  shown  that  the  oil  itself  may 
become  mixed  with  inspissated  intestinal  mucus  and  form  small, 
hardened  masses,  which  have  been  mistaken  for  gallstones.  There 
is  no  foundation  for  the  belief  that  oil  is  of  any  value  for  cholelithia- 
sis, and  it  is  not  rational  to  suppose  that  it  enters  the  bile  ducts  to 
"  lubricate  "  them. 

Fats  and  oils  are  useful  preservatives  of  many  foods  by  prevent- 
ing access  of  air,  drying,  and  decomposition.  A  layer  of  oil  floating 
on  top  of  a  flask  of  wine  is  capable  of  preserving  its  delicacy  of 
flavour  for  a  long  time  (Chambers).  Oil  preserves  fish,  like  sardines, 
and  layers  of  lard  are  used  to  protect  jars  of  potted  meats, /i//-^^- 
fois-gras,  etc.     Oils  and  butter  protect  eggs  from  decomposition. 

Digestibility  of  Fats. — There  is  some  difi'erence  of  opinion  as 
to  what  extent  fat  may  aid  or  retard  the  process  of  digestion,  but 
it  is  a  matter  of  very  common  experience  that  those  persons  whose 
digestive  organs  are  feeble  do  not  tolerate  fats  or  oils  well  when 
eaten  with  other  forms  of  food.  This  is  no  doubt  owing  to  the  fact' 
that  fats  are  practically  unaltered  in  the  mouth  and  stomach,  and 
in  the  latter,  when  melted,  they  coat  the  mucous  membrane  and 
surround  the  particles  of  food  with  a  thin  film  which  materially 
interferes  with  the  normal  action  of  the  gastric  juice.  For  this 
reason  fats  are  to  be  avoided  by  dyspeptics,  and  the  fats  selected  for 
special  nutritive  processes  should  be  in  the  form  of  good  butter, 
cream,  or  cod-liver  oil.  On  the  other  hand,  fats  may  sometimes  aid 
the  digestibility  of  starchy  foods  by  preventing  them  from  forming 
lumpy  masses  in  the  mouth  and  stomach.  For  example,  a  well- 
roasted  mealy  potato  may  be  made  all  the  more  digestible  for  an 


FATS   AND   OILS. 


175 


invalid  by  being  mashed  with  a  little  butter  or  cream.  There  is  no 
practical  method  by  which  the  digestibility  of  fats  may  be  improved 
in  the  sense  that  the  digestibility  of  meat  is  improved  by  converting 
it  into  peptones.  Artificial  emulsions  make  oils  somewhat  more 
palatable,  but  the  simple  oil  is  sometimes  better  borne  than  such 
preparations. 

It  is  stated  by  Ringer  that  fats  taken  fasting  lessen  the  secretion 
of  bile,  whereas  if  taken  with  or  after  food  they  increase  it,  but,  as 
many  kinds  of  food  promote  the  secretion  independently  of  fat,  it 
is  doubtful  whether  the  latter  possesses  any  very  decided  action  in 
relation  to  bile  formation. 

Most  of  the  fat  used  as  food  melts  at  the  temperature  of  the  body, 
which  facilitates  its  digestion. 

Children  often  eat  butter  more  readily  than  any  other  form 
of  fat. 

As  a  rule,  the  stomach  is  less  disturbed  by  animal  than  by  vege- 
table fats  taken  in  excess,  and  the  former  may  be  tolerated  for  a 
longer  time.  The  limit  of  digestibility  of  increasing  quantities  of 
food  is  much  sooner  reached  with  fats  than  with  other  articles  of 
diet,  and  they  produce  satiety  early  in  a  meal,  but,  as  in  the  case  of 
many  foods,  toleration  may  be  acquired  for  the  ingestion  of  fat, 
which  is  exemplified  in  the  fact  that  many  persons  who  cannot  digest 
cod-liver  oil  completely  at  first  may  do  so  after  two  or  three  weeks' 
trial.  This  is,  in  part,  due  also  to  the  general  improvement  in  health 
which  follows  in  some  cases  the  administration  of  easily  digested 
fat.  Overdoses  of  fat  at  any  time  are  apt  to  give  rise  to  the  forma- 
tion of  irritating  acids  which  cause  nausea  and  vomiting,  with  pos- 
sibly abdominal  cramps  and  loose  evacuations.  Fat  taken  too  liber- 
ally with  other  food  ceases  to  be  economical  for  the  system  and 
becomes  positively  harmful. 

Since  fat  is  exclusively  digested  in  the  small  intestine,  diseases  of 
any  part  of  the  alimentary  canal  are  contraindications  for  its  use. 

Liquefied  fats  and  oils  are  usually  administered  as  a  matter  of 
routine  when  corrosive  poisons  have  been  swallowed,  with  the  idea 
that  they  coat  over  the  mucous  membrane  of  the  stomach  and 
oesophagus  and  protect  them  from  the  action  of  the  irritant.  This 
protective  action  is  overestimated,  for  it  is  difficult  to  coat  to  a 
sufficient  degree  a  mucous  membrane  which  is  already  moistened 
with  watery  mucus. 

The  digestibility  of  all  fat  depends  somewhat  upon  its  cooked 
state.  Many  persons  are  nauseated  or  made  dyspeptic  by  eating 
hot  mutton  fat  who  can  eat  the  same  with  impunity  when  it  is  cold. 
In  the  latter  condition  it  becomes  more  friable  and,  if  thoroughly 
mixed  in  chewing  with  starchy  food,  or  used  as  suet  in  the  form  of  a 
farinaceous  pudding,  it  becomes  very  much  more  digestible.  Chil- 
14 


176 


FOODS   AND   FOOD   PREPARATIONS. 


dren  usually  dislike  fat  meat,  but  they  are  quite  willing  to  take  suet 
puddings,  which,  if  light  and  well  cooked,  are  wholesome. 

While  the  various  fats  and  oils,  in  general,  have  the  same  bene- 
ficial effect  upon  nutrition,  there  is  considerable  difference  in  their 
force  value  and  in  the  facility  with  which  one  variety  or  another  may 
be  assimilated  in  individual  cases.  The  animal  fats  have  a  higher 
nutritive  power  than  those  derived  from  vegetables,  and  liver  fat, 
butter  and  cream,  art!  the  most  serviceable  of  all. 

Animal  Fats. 

The  principal  animal  fats  and  fatty  foods  are  butter,  cream,  suet, 
lard,  oleomargarine,  the  fat  of  beef,  mutton,  pork  and  bacon,  bone 
marrow,  pemmican,  fish,  and  cod-liver  oil.  Oil  is  also  made  from 
the  yolk  of  eggs. 

Butter  and  cream  hafe  been  discussed  under  the  heading  Milk 
Derivatives  (pp.  82-84). 

Lard  is  hog  fat  separated  by  melting  from  the  areolar  connective 
tissue.  Considerably  over  half  a  billion  pounds  are  annually  pro- 
duced in  the  United  States. 

Crude  lard  contains  glycerides  of  oleic,  stearic,  and  palmitic  acids, 
besides  a  little  gelatin  and  other  substances. 

"  Cuisine  "  is  a  preparation  of  cotton-seed  oil  designed  to  replace 
lard  and  cheap  cooking  butter. 

"  Cottolene  "  is  another  such  substitute  for  cooking  purposes. 

Stearins  are  the  solid  residue  of  animal  fats  remaining  after  pres- 
sure has  separated  the  fiuid  fats.  They  are  used  in  making  com- 
pound lard,  butterine,  and  similar  foods. 

Tallow  is  a  general  term  originally  applied  to  all  fat  tried  from 
the  different  tissues  of  cattle. 

Suet  is  the  fat  which  surrounds  the  kidney. 

Oleomargarine. — Oleomargarine  was  invented  in  1870  by  a  French 
chemist,  Mege-Mourier,  who  discovered  that  beef  fat  from  particular 
portions  of  the  bullock  would  melt  at  the  same  temperature  with 
butter,  and  would  keep  longer  without  becoming  rancid.  The  fresh 
fat  is  mashed  in  a  grinding  machine  to  free  it  from  membrane.  "  The 
fragments  fall  into  a  tank  heated  with  steam,  which  for  every  thou- 
sand parts  of  fat  contains  three  hundred  parts  of  water  and  one  part 
of  carbonate  of  potash  and  two  stomachs  of  sheep  or  pigs.  The 
temperature  of  the  mixture  is  raised  to  45°  C."  (Clark). 

After  two  hours  the  fat  is  withdrawn  from  the  membranes,  which 
have  been  digested  away,  and  is  heated  still  more  with  the  addition  of 
2  per  cent  of  salt.     It  is  then  cooled,  pressed,  and  packed  for  market. 

Much  discussion  has  arisen  in  regard  to  the  wholesomeness  of 
oleomargarine,  and  its  sale  has  been  regulated  by  act  of  Congress 
since  1886  and  by  many  State  laws.     It  has  been  declared  perfectly 


FATS   AND   OILS. 


177 


innocuous,  and  the  object  of  the  legal  control  of  its  sale  is  mainly 
intended  to  prevent  it  from  being  fraudulently  offered  as  butter.  It 
certainly  tastes  better  than  poor  butter.  According  to  Clark,  forty- 
five  billion  pounds  of  oleomargarine  were  sold  throughout  the  United 
States  in  1883  (Report  of  United  States  Commissioners  to  the  Paris 
Exposition,  1889) ;  therefore  it  takes  high  rank  as  a  food  product. 

Butterine,  which  has  now  largely  replaced  oleomargarine  in  this 
country,  is  made  in  a  similar  manner,  but  with  a  somewhat  different 
proportion  of  ingredients,  and  some  of  the  leaf  fat  of  the  hog  is 
added  during  the  manufacture.  The  United  States  law,  however, 
still  requires  all  products  of  this  general  class  to  be  branded  "oleo- 
margarine." 

Beef  Fat,  Pork,  etc. — Beef,  mutton,  and  pork  fat  consist  prin- 
cipally of  the  glycerides  of  such  common  fatty  acids  as  stearic, 
palmitic,  and  oleic. 

The  fat  of  good  roast  beef  is  nutritoius,  and  a  very  digestible 
variety  of  fat  is  good  bacon  thinly  sliced  and  thoroughly  cooked. 
This  form  of  fat  is  crisp  and  dry,  and  it  is  often  digested  by  invalids 
who  cannot  tolerate  other  kinds.  Ham  fat  and  pork  fat,  on  the  other 
hand,  are  usually  very  indigestible — the  more  so  when  hot. 

Bone  Marrow. — Bone  marrow  is  an  easily  digestible  and  whole- 
some fat  which  has  long  been  used  as  a  food.  The  long  bones  of 
the  ox  are  cut  crosswise  in  pieces  about  two  inches  in  length  and 
cooked  with  the  marrow  within  them.  It  has  quite  lately  been  sug- 
gested that  red  marrow  might  prove  a  useful  food  in  cases  of  anaemia 
and  chlorosis,  because  the  red  blood-corpuscles  are,  in  part  at  least, 
made  from  the  cells  contained  in  it.  But  few  cases  treated  with  this 
food  have  as  yet  been  reported,  and  it  is  doubtful  whether  the  mar- 
row acts  otherwise  than  in  furnishing  an  assimilable  fat  to  patients 
who  are  much  in  need  of  such  food,  and  also  a  very  digestible  form 
of  iron,  which  exists  in  it  in  considerable  quantity.  The  marrow  of 
young  animals,  such  as  the  calf  or  lamb,  is  preferred  for  this  pur- 
pose, because  their  tissue-building  power  is  so  active.  Fraser  re- 
ported the  first  case  of  anaemia  treated  by  means  of  marrow,  and  he 
prefers  a  glycerin  extract.  Mann  reports  a  case  of  haemophilia  and 
pronounced  anaemia  which  yielded  to  teaspoonful  doses  given  twice 
a  day  on  bread,  and  this  after  other  remedies  had  failed.  He  cites 
several  other  favourable  cases  (Lancet,  December,  1893). 

J.  S.  Billings,  Jr.  (Johns  Hopkins  Hospital  Bulletin,  November, 
1894,  p.  115),  has  used  a  similar  preparation  made  as  follows: 

"Twelve  sheep's  ribs,  carefully  scraped,  were  chopped  into  small 
fragments  and  rubbed  in  a  mortar  with  one  pound  of  glycerin.  This 
was  allowed  to  macerate  for  three  or  four  days,  being  kept  in  a  re- 
frigerator during  that  time.  It  was  then  strained  through  gauze, 
and    the  resultant    liquid   administered  in   teaspoonful   doses  three 


178  FOODS   AND   FOOD    PREPARATIONS. 

times  a  day.  No  complaint  was  made  by  the  patients  with  regard  to 
its  taste." 

Walker,  of  New  York,  uses  a  sort  of  emulsion  made  by  mixing 
thoroughly  the  red  marrow  of  the  long  bones  of  the  ox  with  Cetraria 
(Iceland  moss).  This  makes  an  exceedingly  agreeable  preparation, 
a  whitish  paste  pleasant  to  the  eye,  and  tasting  not  unlike  good  but- 
ter. It  may  be  spread  upon  bread  and  eaten  three  or  four  times  a 
day. 

Pemmican  is  made  of  meat  cut  into  slices  and  thoroughly  dried  in 
the  sun  ;  to  this  are  added  fat,  sugar,  and  dried  fruit,  such  as  raisins 
and  currants.  It  is  used  on  long  voyages,  especially  to  the  Arctic 
circle,  where  a  fatty  diet  is  essential  to  furnish  heat  and  force  to  en- 
able the  body  to  withstand  the  rigour  of  the  climate.  It  is  easily 
masticated,  and  the  sweet  fruit  promotes  the  flow  of  saliva. 

Brains  and  liver  contain  considerable  fat. 

The  common  fish  which  contain  most  fat  are  eels,  salmon,  herring, 
and  mackerel.  Sardines  contain  some  fat,  but  derive  most  of  it  from 
the  oil  in  which  they  are  immersed  for  preservation. 

Many  fish  oils  have  special  uses.  The  Eskimos  eat  whale  and 
seal  oil  and  blubber,  and  dugong  oil  is  eaten  to  some  extent  in  Aus- 
tralia. The  oil  of  the  sturgeon  is  employed  for  preserving  caviare. 
Turtle  oil  and  butter  is  made  extensively  in  Brazil  from  both  the  eggs 
and  fat  of  the  reptile  (Clark). 

Cod-liver  oil  will  be  separately  considered. 

£ggs  contain  considerable  fat  in  their  yolks.  Some  eggs,  like  the 
plover's,  are  very  rich  in  this  ingredient.  They  have  already  been 
described  in  detail  (see  Eggs,  p.  89). 

Vegetable  Fats  and  Oils. 

The  principal  vegetable  fats  or  oils  and  fatty  foods  are  derived 
from  seeds.  Such  foods  are  olives,  olive  oil,  cotton-seed  oil,  and  nuts. 
Traces  of  fat  are  found  in  the  legumes. 

Olive  Oil. — Olives  and  olive  oil  constitute  a  very  digestible  form 
of  fatty  food,  and  may  sometimes  be  eaten  by  consumptives  in  lieu 
of  cod-liver  oil.  French  olives  gathered  while  young  and  tender  are 
very  wholesome. 

Olive  oil  is  made  by  crushing  the  fruit  with  stones,  after  which 
the  pulp  is  pressed  in  bags.  The  first  oil  thus  obtained  is  the  best. 
A  second  oil  is  got  by  adding  boiling  water  to  the  pulp  residue,  and 
pressing  it  again.  This  oil  is  more  apt  to  become  rancid  than  the 
first  (Clark).  The  best  oil  generally  obtamable  is  from  France  and 
Italy,  but  an  excellent  quality  is  manufactured  in  Southern  Califor- 
nia. The  paler  variety  is  the  best,  but,  unfortunately,  it  is  constantly 
adulterated  or  imitated  (see  also  Olives). 

Cotton-seed  oil,  and  to  some  extent  poppy-seed  oil,  are  now  fre- 


FATS   AND   OILS. 


179 


quently  substituted  for  olive  oil  in  the  preparation  of  various  foods, 
and  the  sardines  which  were  formerly  preserved  in  pure  olive  oil  are, 
for  the  most  part,  immersed  in  cotton-seed  oil.  This  oil  is  not  ran- 
cid, but  its  flavour  and  odour,  which  resemble  linseed  oil,  are  not 
agreeable  when  it  is  eaten  raw  with  salads  or  fish,  and,  unless  ex- 
tremely pure,  it  leaves  an  unpleasant  after-taste  in  the  mouth.  It  is 
composed  principally  of  palmitin  and  olein.     It  is  a  harmless  food. 

Linseed  oil  is  sometimes  substituted  for  olive  oil,  but  it  is  not  very 
digestible. 

Cacao  butter^  oil  of  theobroma,  is  a  firm  oil  obtained  from  ca- 
cao seeds  during  the  manufacture  of  chocolate.  It  easily  melts  at 
the  body  temperature.  It  is  used  for  inunctions  and  for  making 
suppositories,  and  sometimes  as  an  ingredient  of  infant  foods,  such 
as  lactopreparata. 

Nuts,  especially  English  walnuts,  cocoanuts,  hickory,  pecan,  and 
Brazil  nuts,  all  contain  a  good  deal  of  vegetable  oil  (see  Nuts). 

The  oil  of  nuts  which  have  been  too  long  kept  sometimes  becomes 
rancid  and  unwholesome. 

Cocoanut  oil  \%  principally  used  in  Oriental  countries. 

Peanut  oil  is  used  to  some  extent  in  this  country,  like  cotton-seed 
oil,  mainly  to  adulterate  or  imitate  olive  oil,  which  is  much  more  ex- 
pensive. 

Java  almond  oil  may  also  be  used  for  cooking. 

Dietetic  Uses  of  Fats  and  Oils. — Since  fats  are  essential  for 
growth  and  nutrition  as  well  as  force  production,  fatty  food  is  indi- 
cated for  convalescence  from  severe  acute  diseases,  and  for  patients 
suffering  from  chronic  wasting  diseases,  in  both  of  which  classes 
there  has  been  considerable  waste  of  the  tissues.  Persons  whose 
general  health  has  been  impaired  by  bad  hygienic  surroundings,  chil- 
dren who  have  been  wrongly  fed  by  ignorant  or  poor  parents  who 
could  not  obtain  proper  food  for  them,  and  aged  persons  in  whom 
the  nutritive  processes  are  becoming  less  and  less  vigorous,  may  all 
be  benefited  by  supplying  a  sufficient  amount  of  fatty  food  in  the 
dietary.  For  scrofulous  and  tuberculous  patients  fats  are  especially 
indicated.  There  is,  therefore,  a  very  large  variety  of  diatheses  and 
of  actual  diseases,  both  local  and  general,  which  may  be  benefited 
by  improving  the  nutrition  of  the  body  and  increasing  force  produc- 
tion through  the  agency  of  easily  digestible  forms  of  fatty  foods. 

Diseases  in  which  Fats  are  Particularly  Beneficial. — Tu- 
berculosis, pulmonary  as  well  as  other  forms;  scrofulous  conditions; 
chronic  wasting  diseases  with  secretion  of  pus,  as  empyema,  chronic 
abscesses,  etc. ;  marasmus  ;  rickets ;  chronic  bronchitis ;  many  chronic 
diseases  of  the  skin  and  nervous  system. 

Diseases  in  which  the  Use  of  Fats  should  be  forbidden 
or  restricted. — All  forms  of  acute  gastro-intestinal  disease;  chronic 


l80  FOODS   AND   FOOD   PREPARATIONS. 

gastritis ;  dilatation  of  the  stomach  ;  chronic  diarrhoea  ;  obesity  ;  fatty 
and  waxy  liver ;  gallstones;  acne;  urticaria. 

Generally  speaking,  fats  are  laxative,  and  oils  should  not  be  given 
in  cases  of  diarrhoea  or  intestinal  disorder. 

By  most  persons  fat  cannot  be  eaten  continuously  in  large  quan- 
tity without  producing  indigestion.  The  stools  become  offensive  and 
diarrhoeal,  there  is  apt  to  be  nausea  and  gastric  indigestion,  and  dis- 
gust for  such  a  diet  very  soon  arises.  There  are  some  individuals 
who  are  unable  to  digest  fats  in  any  amount,  however  small,  and 
they  must  derive  all  their  energy  from  carbohydrates. 

Glycerin. — Glycerin  plays  an  inconspicuous  role  as  a  food.  It 
is  mainly  useful  for  its  sweetish  taste  as  a  substitute  for  sugar  in  the 
diet  of  diabetics,  but  to  many  persons  the  taste  of  glycerin  itself  is 
nauseous.  It  is  now  largely  superseded  by  saccharin.  It  is  highly 
hygroscopic,  and  if  taken  in  the  mouth  undiluted  makes  the  mucous 
membrane  sticky  and  unpleasant,  but  it  is  often  used  as  a  mouth 
wash  in  a  diluted  form  in  the  proportion  of  a  drachm  to  the  ounc.e. 
The  mouth  may  be  rinsed  or  swabbed  with  it  in  cases  of  acute  fever, 
such  as  typhoid,  where  the  mucous  surface  has  become  dried  or  the 
tongue  is  glazed  or  fissured.  It  acts  by  protecting  the  mucous  mem- 
brane from  evaporation,  making  the  mouth  a  little  more  comfortable. 
In  such  cases  it  sometimes  diminishes  thirst,  although  its  effect  in 
this  respect  is  very  uncertain.  Glycerin  is  also  quite  laxative,  and 
it  may  be  given  either/<?r  os  or  in  the  form  of  the  well-known  glyc- 
erin suppositories  for  the  purpose  of  increasing  peristaltic  action  and 
evacuating  the  bowels. 

Cod-liver  Oil. 

The  best  cod-liver  oil  is  known  as  "  cold-drawn  oil,"  and  is  pre- 
pared from  the  raw  fresh  livers  of  the  codfish  by  subjecting  them  to 
heavy  pressure,  by  which  the  oil  is  squeezed  out. 

Chemical  and  Physical  Properties. — Cod-liver  oil,  according 
to  analyses  made  by  De  Jongh,  contains  glycerin,  olein  (70  per  cent), 
myristic,  butyric,  acetic,  margaric,  and  other  acids,  biliary  elements 
such  as  cholesterin,  also  iodine,  bromine,  chlorine,  and  phosphorus 
in  small  amount,  and  a  peculiar  material  which  is  called  "gaduin." 
Gautier  and  Mourges  obtained  besides  a  half  dozen  substances  re- 
sembling alkaloids  and  other  materials,  a  basic  substance  which  they 
call  morrhuine,  about  one  half  milligramme  of  which  occurs  in  each 
gramme  of  the  oil,  and  has,  it  is  claimed,  all  of  its  active  medicinal 
properties. 

The  refined  oil  may  contain  no  iodine,  and  it  is  seldom  present 
in  greater  amount  than  0.5  per  cent;  hence  the  value  of  the  oil  does 
not  depend  upon  this  substance,  as  at  one  time  suggested. 

When  pure,  its  odour  resembles  shoe  leather.     On  adding  strong 


FATS   AND   OILS.  -  igf 

acid,  the  biliary  odour  is  intensified  if  the  oil  is  unadulterated.  If 
the  odour  is  absent,  the  oil  is  spurious. 

Cod-liver  oil  is  one  of  the  most  easily  absorbed  of  all  the  oils, 
owing  to  the  quantity  of  its  fatty  acids.  It  is  quickly  oxidised  in 
the  body.  It  is  highly  nutritious  and  alterative,  and  is  slightly 
laxative,  especially  for  infants. 

Some  of  the  oil  supplied  in  market  is  derived  from  the  livers  of 
other  fishes  than  the  cod,  but  the  cod-liver  oil  is  undoubtedly  the 
best.  Pains  should  be  taken  to  secure  a  pure  preparation  thoroughly 
clarified  from  the  impurities  which  oil  may  contain,  such  as  traces  of 
iodine,  phosphorus,  and  sometimes  bile  salts.  None  of  these  sub- 
stances add  to  its  food  value,  and,  if  present  in  excess,  the  oil  is 
much  more  apt  to  disagree. 

The  crude  "  straits  "  oil  contains  products  of  decomposition,  is 
strong,  malodorous,  and  of  a  dark-brown  or  even  black  colour.  It 
is  so  disagreeable  and  indigestible  that  it  possesses  no  advantage 
over  the  "  shore  "  oil.  The  clarified  Norwegian  oil  is  the  best  variety 
to  prescribe. 

Cod-liver  oil  is  sometimes  adulterated  with  the  cheaper  cotton- 
seed oil,  to  which  a  fishy  flavour  is  artificially  given,  and  it  should 
therefore  only  be  purchased  from  a  well-known  and  responsible  firm. 

An  advantage  of  cod-liver  oil  is  that  when  pure  it  can  be  taken 
longer  than  any  other  fat  excepting  butter  and  cream,  and  in  larger 
quantities  than  those  substances  without  disordering  the  stomach. 
This  is  no  doubt  owing  to  the  fact  that  the  oil  is  already  in  a  con- 
dition in  which  it  has  once  served  in  the  animal  body  for  nutrition 
or  at  least  for  storing  up  energy.  This  form  of  oil  is  readily  emul- 
sified and  saponified,  and  is  absorbed  by  the  intestinal  villi  with 
probably  greater  facility  than  any  other  fat. 

Dosag^e. — Many  patients  who  dislike  the  taste  of  the  oil  at  first 
soon  acquire  tolerance  for  it  if  given  in  small  and  gradually  increas- 
ing dosage,  commencing  sometimes  with  not  over  lo  to  30  drops 
twice  a  day,  and  children  not  rarely  become  so  fond  of  it  as  to  ob- 
ject to  its  discontinuance.  Infants  may  be  given  from  5  to  20  drops 
two  or  three  times  a  day.  It  is  so  valuable  a  food  that  where  its  use 
is  clearly  indicated  every  effort  should  be  made  to  secure  its  tolera- 
tion, and  even  though  it  may  at  first  disagree,  exciting  nausea  and 
vomiting,  perseverance  and  care  in  its  administration  may  enable  it 
to  be  very  well  borne.  If  it  is  not  digested  at  first,  but  one  dose  of 
two  or  three  teaspoonfuls  a  day  need  be  given,  and  this  should  be  at 
night. 

Those  who  like  it  can  sometimes  take  as  much  as  an  ounce  three 
times  a  day  with  advantage,  although  half  an  ounce  is  all  that  can 
usually  be  tolerated  without  disturbing  digestion. 

The  oil  must  be  given  under  proper  supervision  if  its  successful 


1^2  FOODS   AND   FOOD   PREPARATIONS. 

use  is  to  be  continued ;  otherwise  it  defeats  its  own  object  by  upset- 
ting digestion.  Patients  who  dose  themselves  with  it  often  use  too 
much,  and  almost  invariably  take  it  at  the  wrong  time  in  relation -to 
meals. 

It  is  best  to  prescribe  it  about  an  hour  after  dinner.  If  given 
earlier,  it  remains  in  the  stomach,  interfering  with  the  digestion  of 
other  food,  whereas  if  digestion  is  already  well  under  way,  it  passes 
with  the  chyme  into  the  intestine,  where  it  is  absorbed.  While  the 
oil  is  being  taken  the  stools  should  be  occasionally  examined,  as  the 
absence  of  fat  globules  in  them  is  a  proof  of  its  complete  absorp- 
tion. 

Methods  of  Administration. — Many  patients  can  take  perfectly 
pure,  well-clarified  cod-liver  oil  better  than  the  emulsions  and  prep- 
arations in  which  it  is  offered  in  the  market,  while  others  prefer  it 
in  the  form  of  the  so-called  emulsions  with  hypophosphites  of  lime, 
soda,  or  iron,  or  with  other  substances.  Some  of  these  emulsions  are 
rendered  almost  tasteless,  while  others  are  flavoured  with  winter- 
green,  ginger,  or  some  other  aromatic. 

Emulsions  are  seldom  as  good  as  the  pure  oil,  and  are  only  to  be 
preferred  when  the  latter  is  not  digested  or  when  the  taste  proves  too 
nauseous.  They  usually  do  not  contain  above  50  per  cent  of  the 
oil,  and  often  only  ;^;^  per  cent;  hence  the  dose  is  unnecessarily 
bulky.  Moreover,  they  rapidly  deteriorate  with  age,  so  that  if  emul- 
sions are  to  be  used  they  should  be  freshly  made  with  yolk  of  egg 
and  glycerin  or  mucilage  of  tragacanth. 

Dr.  James  Stewart,  of  Montreal,  gives  excellent  formulae  for  this 
purpose  as  follows  : 

Cod-liver  oil - 6  ounces. 

Oil  of  wintergreen i  drachm. 

Chloroform 2  drachms. 

Glycerin,  yolk  of  egg,  each 5        " 

Orange-flower  water,  sufficient  to  make 12  ounces. 

M.     Dose,  one  tablespoonful. 

This  is  not  too  thick. 

Cod-liver  oil 6  ounces. 

Oil  of  wintergreen  (or  any  essential  oil) i  drachm. 

Mucilage  of  tragacanth 2  ounces. 

Orange  water,  sufficient  to  make 12     " 

M.     Dose,  one  tablespoonful. 

This  emulsion  is  somewhat  thicker  than  the  preceding  one. 

Oil  of  bitter  almonds  may  be  used  in  the  proportion  of  three 
drops  to  the  ounce,  instead  of  the  wintergreen  oil, 

Lefaki  recommends  an  emulsion  made  with  an  equal  part  of  lime 
water,  flavoured  with  lemon  sirup  or  vanilla.  This  can  be  pre- 
scribed when  diarrhoea  exists.    Another  method  is  to  add  two  ounces 


FATS   AND   OILS.  jgj 

of  finely  chopped  and  strained  fresh  pancreas  to  the  gallon  of  oil  to 
produce  an  emulsion. 

Stewart  suggests  rinsing  the  mouth  before  taking  the  oil  with  a 
i-per-cent  solution  of  cocaine  or  with  undiluted  brandy  or  whisky 
and  two  or  three  drops  of  oil  of  peppermint.  Children  may  be  given 
a  peppermint  lozenge.  If  preferred,  the  dose  of  pure  oil  may  be 
poured  upon  the  surface  of  some  fluid,  such  as  orange  or  ginger 
bitters,  strong  black  coffee,  lemon  juice,  weak  brandy  and  water,  el- 
even ale  or  beer.  Pains  should  be  taken  to  float  the  oil  in  the  centre 
of  the  surface  of  the  fluid,  so  that  it  is  to  some  extent  coated  by  it 
and  does  not  come  in  contact  with  the  glass  or  cup  and  produce  a 
lingering,  disagreeable  taste  in  the  mouth.  Ringer  suggests  adding 
a  few  drops  of  catsup  to  disguise  the  taste,  or  the  use  of  a  mixture 
of  equal  parts  of  the  oil  and  fresh  aqueous  solution  of  gum  acacia 
with  two  minims  of  oil  of  lemons  added  to  each  ounce.  A  little  salt 
taken  in  the  mouth  before  and  after  each  dose  may  neutralise  the 
taste.  He  also  refers  to  the  use  of  a  cod-liver-oil  jelly  containing 
70  per  cent  of  the  oil.  This  disguises  the  flavour.  The  oil  is  some- 
times given  with  different  preparations  of  meat  juice. 

In  this  country  cod-liver  oil  is  extensively  used  in  the  form  of 
capsules  of  gelatin  which  are  shaped  like  an  olive,  and  which  some 
patients  can  swallow  with  ease,  although  they  are  rather  bulky  and 
not  always  reliable.  A  child  of  ten  years  recently  came  under  my 
observation  who  for  some  time  previously  had  been  given  four  or 
five  of  these  capsules  daily,  each  containing  a  teaspoonful  of  cod- 
liver  oil.  She  had  developed  an  exceedingly  irritating  stomach 
cough,  for  which  a  variety  of  sedatives  had  been  administered  with- 
out any  effect.  To  my  astonishment,  she  at  one  time  vomited  seven- 
teen of  the  undissolved  capsules,  which  represented  four  or  five 
days'  dosage. 

The  oil  is  sometimes  administered  in  the  form  of  "oleochyle," 
in  which  it  is  claimed  it  has  been  predigested  and  rendered  easier  of 
absorption. 

Claude  Bernard,  to  whom  we  are  indebted  for  much  valuable 
research  upon  the  physiology  of  digestion,  first  showed  that  ether 
given  by  the  mouth  acts  as  a  stimulant  to  the  secretion  of  the  pan- 
creas and  the  glands  of  Brunner  which  aid  the  digestion  of  fat,  and 
that  it  increases  the  absorption  of  fats.  Acting  upon  this  sugges- 
tion. Dr.  Balthazer  Foster  found  that  pure  ether  added  to  fats  and 
oils  in  the  proportion  of  five  or  six  minims  to  a  drachm  of  the  oil 
would  often  insure  its  digestion,  whereas  previously  it  had  excited 
nausea  and  vomiting,  and  this  method  has  proved  of  service  in  the 
hands  of  others.  The  ether  itself  disguises  somewhat  the  taste  of 
the  oil,  but  I  have  sometimes  found  it  to  produce  disagreeable  eruc- 
tations.    In  fact,  in  some  hospitals  a  "  malingerer's  mixture  "  has 


,,g^  FOODS   AND   FOOD   PREPARATIONS. 

been  employeJ  composed  of  a  disagreeable  combination  of  ether, 
oil,  and  asafoetida  which  has  the  result  of  causing  eructations  and, 
maintaining  an  exceedingly  disagreeable  taste  in  the  mouth.  Lime 
water  is  sometimes  added  to  cod-liver  oil  to  produce  a  temporary 
emulsion,  and  it  may  prevent  nausea. 

Cod-liver  oil  is  advantageously  combined  with  malt,  and  when 
not  so  sweet  as  to  be  disliked  by  the  patient  it  proves  a  very  service- 
able food.  Cod-liver  oil  is  added  in  the  proportion  of  30  per  cent  to 
maltine,  or  50  per  cent  to  malt  extract. 

In  very  hot  weather  it  is  usually  best  to  suspend  the  adminis- 
tration of  oil,  as  it  is  apt  to  disagree,  even  if  it  does  not  become 
rancid. 

Substitutes. — Many  substitutes  for  cod-liver  oil  have  been  pro- 
posed, but  it  is  doubtful  whether  any  of  them  can  be  made  to  yield 
all  the  benefits  to  be  derived  from  the  genuine  substance. 

Efforts  have  long  been  made  to  determine  whether  the  alkaloidal 
or  other  substances  obtainable  from  cod-liver  oil  do  not  possess  all 
the  nutritive  and  stimulating  properties  of  the  oil  itself  in  equal  or 
even  greater  degree.  Some  of  them  are  doubtless  capable  of  produ- 
cing active  symptoms,  but  if  the  oil  itself  is  a  true  food,  there  can  be 
no  advantage  in  attempting  to  concentrate  it  beyond  the  minor  con- 
sideration of  avoiding  its  nauseous,  fishy  taste.  M.  Chapoteau  de- 
scribes a  crystalline  substance  which  he  terms  morrhuol,  and  which 
exists  in  the  oil  in  the  proportion  of  1.5  to  6  per  cent,  the  lesser 
quantity  being  found  in  the  purest  oil.  It  is  claimed  that  three  to 
five  drops  of  this  substance  possess  all  the  properties  of  a  drachm  of 
Cod-liver  oil.  It  may  be  given  in  capsules  or  disguised  with  olive 
oil,  fat,  or  cream.  Much  interest  is  at  present  manifested  in  testing 
the  clinical  worth  of  preparations  of  this  class,  but  although  their 
use  has  been  favourably  reported  by  some  observers  within  the  past 
year  or  two,  further  evidence  is  required  before  their  general  substi- 
tution for  the  oil  itself  can  be  indorsed. 

Von  Mehring  and  Hauser  recommend  "  lipanin,"  made  by  add- 
ing to  olive  oil  6  per  cent  of  oleic  acid.  This  is  devoid  of  disagree- 
able taste  and  odour,  and  may  be  given  in  doses  of  from  one  to  four 
teaspoonfuls  three  times  a  day. 

Uses. — Cod-liver  oil  is  not  a  specific  for  any  disease,  and  there 
are  many  clinicians  who  prefer  to  prescribe  other  forms  of  fat  when 
possible.  Fothergill  wrote  that  "  out  of  five  persons  taking  cod-liver 
oil  probably  only  two  require  fat  in  that  particular  form,  while  three 
take  it  because  it  is  the  only  fat  put  up  in  such  a  form  as  can  be 
readily  purchased." 

Nevertheless,  there  are  often  seen  cases  of  phthisis  in  which  a 
decided  gain  in  weight  follows  the  administration  of  a  disproportion- 
ately small  quantity  of  the  oil.     It  is  a  most  useful  food   in  many 


FATS   AND   OILS. 


185 


conditions  of  debility,  and  is  indispensable  in  the  treatment  of  the 
scrofulous  diathesis,  rickets,  marasmus,  and  general  tuberculosis. 

It  is  found  clinically  to  be  of  great  service  in  a  variety  of  forms 
of  chronic  inflammation  and  in  cases  in  which  there  is  old  purulent 
discharge  from  any  part  of  the  body,  as  from  the  middle  ear,  or  from 
a  chronic  abscess,  like  empyema — in  fact,  it  is  of  inestimable  service 
in  all  strumous  conditions  and  chronic  bone  diseases,  such  as  caries 
and  necrosis,  as  well  as  in  general  tuberculosis. 

Among  other  chronic  diseases  for  which  cod-liver  oil  is  recom- 
mended may  be  mentioned  chronic  rheumatism  and  gout,  rheuma- 
toid arthritis,  a  variety  of  skin  affections,  and  advanced  syphilis.  It 
is  of  service  also  in  pulmonary  emphysema  and  in  cases  of  chronic 
bronchitis  with  tenacious  purulent  expectoration,  and  by  many  it  is 
believed  to  be  of  some  specific  value  in  loosening  cough.  It  should 
be  observed  that  oil  when  absorbed  passes  through  the  lymphatic 
system  and  is  carried  with  tolerable  directness  into  the  pulmonary 
circulation,  where  fats  in  general  are  believed  to  be  oxidised.  It  is 
suggested  that  this  fact  may  possibly  have  some  bearing  on  the  in- 
fluence attributed  to  cod-liver  oil  as  an  expectorant,  although  it 
seems  more  probable  that  the  effect  is  derived  from  the  improvement 
produced  upon  the  general  nutrition.  Brunton  attributes  it  to  a 
stimulating  action  upon  the  epithelium  of  the  bronchi.  In  cases  of 
atonic  dyspepsia,  particularly  among  elderly  people,  cod-liver  oil 
often  relieves  the  "  sinking  "  feeling  at  the  epigastrium  and  the  faint- 
ness  of  which  they  complain. 

Ringer  recommends  cod-liver  oil  for  vertigo  in  the  aged  which 
originates  from  feeble  heart  action,  and  for  chronic  endocarditis  in 
children.  It  is  also  serviceable  in  relieving  constipation  in  young 
infants,  and  it  may  be  sometimes  given  with  advantage  in  lieu  of  cas- 
tor oil.  Its  loosening  effect  is  more  decided  in  children  than  in 
adults,  and  it  is  less  apt  to  produce  subsequent  constipation  than 
castor  oil,  besides  being  less  disagreeable  to  take. 

For  marasmus  the  use  of  cod-liver  oil  is  particularly  indicated, 
and  in  infants  when  diarrhoea  obtains,  some  benefit  may  be  derived 
from  the  topical  application  of  the  oil  to  the  skin.  To  scrofulous 
children  of  the  emaciated  marasmic  type  in  whom  the  skin  is  dry  and 
wrinkled  15  or  20  drops  of  the  oil  may  be  given  at  night  without 
fear  of  increasing  the  diarrhoea. 


PART  II. 
STIMULANTS,   BEVERAGES,   CONDIMENTS. 


STIMULANTS  AND  BEVERAGES. 

It  is  the  almost  universal  experience  of  mankind  that  the  taking 
of  food  and  drink  merely  to  satisfy  the  cravings  of  physical  needs 
does  not  at  the  same  time  wholly  satisfy  the  desire  of  the  mind  for 
occasional  invigoration,  for  restoration  of  bodily  function  after  fa- 
tigue, for  support  during  sustained  muscular  exertion,  for  an  incentive 
to  activity,  and  for  conviviality.  In  some  form  or  other,  although 
in  greatly  varying  degree,  a  stimulant  is  demanded  by  almost  every 
one  to  meet  the  emergencies  with  which  he  is  from  time  to  time 
confronted. 

To  this  end  the  civilised  European  imports  his  tea  from  China, 
his  coffee  from  Java,  his  cocoa  from  Brazil,  his  tobacco  from  America 
or  Cuba,  his  opium  from  India,  and  his  alcohol  from  more  immediate 
neighbours.  His  semicivilised  or  wholly  barbaric  brother  who  lacks 
the  ability  or  means  to  procure  such  refreshment  from  foreign  sources 
relies  upon  his  own  ingenuity  to  devise  fermented  drinks  from  every 
available  substance.  Thus,  the  Tartar  ferments  milk  into  koumiss, 
the  Mexican  ferments  the  aloe  into  pulque,  the  Central  African  fer- 
ments a  wine  from  the  palm,  the  Kamtchatkan  ferments  a  peculiar 
drink  from  a  poisonous  fungus,  and  honey,  rice,  corn,  barley,  rye, 
grapes,  dates — in  fact,  nearly  every  cereal  and  every  fruit — is  in  some 
part  of  the  world  made  to  yield  the  cup  which  cheers,  and  too  often 
inebriates  as  well. 

It  is  true  that  there  are  occasional  individuals  who  find  it  possible 
to  live  without  ever  tasting  even  the  mildest  stimulants  of  any  kind, 
and  there  are  sects  of  men,  like  the  Mohammedans  and  Buddhists,  to 
whom  the  use  of  alcohol  in  every  form  is  absolutely  forbidden  as  a  re- 
ligious crime  ;  but  most  of  them  discover  other  means  of  satisfying  an 
instinctive  craving  for  occasional  stimulation,  and  ready  substitutes 
for  the  prohibited  intoxicants  are  found  close  at  hand  in  hasheesh, 
opium,  excessive  tea  consumption,  etc.  The  economic  and  social 
aspects  of  this  subject  alone  are  of  vast  importance,  and  the  question 

i86 


STIMULANTS   AND   BEVERAGES.  1 87 

of  the  utility  of  stimulants  and  beverages  is  in  itself  no  small  branch 
of  dietetics. 

The  several  substances  classed  under  these  headings  are  found  to 
serve  in  one  or  more  of  the  following  ways : 

I.  To  relieve  thirst  and  introduce  fluid  into  the  circulation, 

II.  As  diuretics. 

III.  As  diaphoretics. 

IV.  As  diluents  of  the  food  and  of  the  waste  material  in  the  body. 

V.  As  stimulants  of  the  nerves  and  other  organs. 

VI.  As  intoxicants. 

VII.  As  demulcents. 

VIII.  As  tonics,  and  to  promote  digestion. 

IX.  As  astringents. 

X.  For  nutrition. 

The  effects  of  all  beverages  and  stimulants  are  far  more  pro- 
nounced if  they  are  taken  into  an  empty  stomach,  which  insures  their 
prompt  absorption. 

I.  To  relieve  thirst  all  fluids  which  are  not  too  sweet  may  be  used, 
but  sour  beverages,  such  as  acid  lemonade  or  raspberry  vinegar,  the 
effervescing  carbonated  waters,  solutions  of  potassium  bitartrate,  or 
dilute  mineral  acids  in  water,  are  generally  the  most  acceptable. 

II.  As  diuretics  the  mineral  waters  and  carbonated  waters  hold 
the  first  rank.  With  many  persons  coffee  is  also  an  active  diuretic. 
So  are  beer,  gin,  champagne,  and,  to  a  lesser  degree,  other  forms  of 
alcohol,  and  tea. 

III.  As  diaphoretics,  hot  spirits  and  water  or  hot  tea  may  be 
used. 

IV.  As  diluents  of  the  ingested  food  and  of  the  waste  material  of 
the  body  the  alkaline  and  carbonated  effervescing  or  bland  waters 
are  the  best. 

V.  As  stimulants  of  the  nerves  and  other  organs,  the  milder  forms 
of  alcoholic  beverages,  diluted  spirits,  tea,  and  coffee  are  used. 

VI.  As  intoxicants,  beers,  ales,  strong  wines,  champagne,  and 
strong  liquors  are  the  most  powerful  agents.  Koumiss  as  originally 
made  in  the  steppes  of  Russia,  and  many  fermented  substances,  are 
also  employed  for  the  same  purpose. 

VII.  As  demulcents,  mucilaginous,  farinaceous,  and  gelatinous 
beverages  are  used  for  fevers,  etc.  Such  are  decoctions  of  Iceland 
moss  [cetraria)  or  Irish  moss,  barley  or  oatmeal  water,  arrowroot  and 
other  light  gruels,  solutions  of  gelatin,  flaxseed  tea,  etc.  When  taken 
hot  they  are  soothing  for  coughs  and  promote  expectoration. 

VIII.  For  use  as  tonics  and  to  aid  digestion  may  be  mentioned 
malt  extracts,  ales,  light  wines,  clarets,  Burgundies,  diluted  brandy  or 
whisky,  chalybeate  and  arsenical  waters,  and  alkaline  waters  drunk 
before  meals. 


1 88  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

IX.  As  astringents,  red  wines  and  tea  are  of  chief  importance. 

X.  For  nutrition,  cocoa,  chocolate,  malt  extracts,  and,  because  of 
the  milk  and  cream  added,  tea  and  coffee. 

Stimulants  have  two  separate  actions  :  First,  a  prompt  exhilarat- 
ing effect  or  exaltation  of  the  nervous  system,  which  endures  for  a 
few  hours,  and,  secondly,  a  period  of  depression  which  usually  bears 
a  more  or  less  definite  relation  to  the  degree  of  previous  excitation. 
The  second  period  is  sometimes  longer  or  more  intense  than  the 
first,  producing  an  actual  balance  of  loss  of  vitality  in  the  system. 

Various  dietetic  drinks  have  been  advocated  for  their  supposed 
specific  action  in  stimulating  a  torpid  liver  and  as  laxatives  or  as 
diuretics ;  such,  for  example,  are  "  herb  teas,"  a  decoction  of  dande- 
lion root  {taraxacum),  etc.,  but  they  are  of  doubtful  efficacy. 

Many  fruit  essences  and  sirups  are  offered  for  sale  for  use  in 
making  cooling  drinks  and  invalid  beverages.  When  thoroughly 
reliable  preparations  are  obtained  they  are  of  good  service,  but 
many  of  them  are  adulterated.  For  example — for  lemonade,  mix- 
tures of  malic,  citric,  and  tartaric  acids  are  often  substituted.  As  a 
rule,  it  is  better  to  extract  the  juice  from  the  fresh  fruit,  and  unless 
large  quantities  are  required,  this  is  almost  as  cheap.  Unfermented 
California  grape  juice  maybe  had  in  very  pure  condition,  and  it 
constitutes  an  excellent  beverage  for  invalids,  being  wholly  free 
from  alcohol. 

The  preparations  under  consideration  may  be  diluted  with  ice 
water,  or  with  any  one  of  the  simple  effervescing  waters,  such  as 
carbonic-acid  water,  Vichy,  Seltzer,  ApoUinaris,  etc. 

Of  all  these  beverages,  lemonade  and  orangeade  are  perhaps  the 
most  useful  in  the  sick-room.  These  are  agreeable,  cooling,  and 
refreshing  in  fevers,  mildly  diuretic,  and  beneficial  in  many  ways. 
A  very  wholesome  drink  is  made  by  putting  the  juice  of  two  lemons 
with  three  or  four  lumps  of  sugar  into  a  tumbler  of  iced  Vichy, 
Seltzer,  or  ApoUinaris,  and  stirring  in  a  saltspoonful  of  bicarbonate 
of  sodium:  to  be  drunk  while  effervescing. 

Root  beer,  sarsaparilla,  and  ginger  ale  are  wholesome  beverages 
when  pure.  Ginger  ale  is  apt  to  cause  colic  unless  a  reliable  article 
is  obtained  from  a  trustworthy  dealer.  It  makes  a  useful  "  long 
drink  "  for  alcoholic  subjects  who  are  attempting  to  recover  from  a 
debauch.  They  crave  some  beverage  which  has  life  and  sparkle, 
and  the  ginger  itself  is  helpful  to  their  stomachs. 

Alkaline  and  Mineral  Waters. — Effervescing  Waters. 

There  are  many  spring  waters  which  are  used  as  beverages  and 
drunk  either  with  or  between  meals.  They  possess,  in  addition 
to  the  properties  of  plain  water,  a  mildly  tonic  effect  upon  the 
mucous  membrane  of  the  stomach,  due  either  to   the  carbon-dioxide 


STIMULANTS   AND   BEVERAGES. 


189 


gas  or  salts,  or  both,  which  they  may  contain,  and,  owing  to  their 
salts  and  water,  they  are  also  diuretic.  Many  of  these  waters  are 
sold  "  plain  " — i.  e.,  without  free  gas,  and  others  either  hold  natural 
CO,  or  are  made  "  sparkling  "  by  having  this  gas  pumped  into  them 
under  pressure. 

These  waters  are  very  useful,  when  taken  half  an  hour  before 
meals,  to  cleanse  the  mucous  membrane  of  the  stomach  and  pre- 
pare it  for  the  reception  of  food.  They  also  serve  to  dilute  and 
wash  out  waste  materials  from  the  system. 

The  effervescing  or  carbonic-acid  waters  are  more  highly 
charged  with  gas  as  sold  from  "  fountains  "  at  the  druggists  or  in 
siphons  than  when  bottled. 

Fruit  sirups  are  combined  in  many  ways  with  soda,  carbonic- 
acid,  or  other  effervescing  waters,  to  make  soda  water  and  similar 
beverages. 

Ginger  ale,  sarsaparilla,  etc.,  are  made  effervescing,  and  are 
often  used  as  cooling  and  refreshing  drinks. 

The  habit  which  some  persons  form  of  drinking  large  quantities 
of  alkaline  waters  independent  of  any  special  needs  of  the  system 
should  be  condemned.  It  leads  to  the  condition  which  Trousseau 
long  ago  described  as  "  mineral-water  cachexia." 

All  the  effervescing  waters  when  drunk  in  excess  are  apt  to 
excite  or  increase  flatulency  and  give  rise  eventually  to  dyspepsia 
and  debility,  especially  when  combined  with  sweet  sirups.  They 
should  be  avoided  in  dilatation  of  the  stomach,  flatulent  dyspepsia, 
and  palpitation. 

Some  waters  are  drunk  for  their  laxative  or  purgative  action, 
and  others  for  the  salts  which  they  contain,  like  those  of  sulphur, 
iron,  or  arsenic.  This  leads  to  the  classification  of  mineral  waters 
into  alkaline,  saline,  chalybeate,  sulphurous,  acidulous,  arsenical,  etc. 

Thermal  waters  are  those  which  issue  hot  from  their  springs. 
Many  persons  believe  that  these  waters  possess  special  properties 
by  virtue  of  their  being  hot,  which  they  lose  as  the  heat  departs, 
but  there  is  no  physiological  ground  for  this  belief. 

Many  table  waters,  like  Poland  water  (a  plain  carbonic-acid 
water),  Vichy,  Johannis,  Apollinaris  and  Seltzer  (effervescing  car- 
bonic-acid waters),  are  used  mainly  as  an  agreeable  table  beverage, 
and  to  dilute  spirits,  wines,  lemonade,  etc.  They  are  cooling,  re- 
freshing, and  wholesome.  People  will  often  drink  fluid  of  this  kind 
who  are  not  willing  to  drink  sufficient  plain  water. 

Johannis  water  is  an  alkaline  carbonated  water  which  comes 
from  a  spring  at  Zollhaus,  in  the  Taunus  Mountains.  It  contains 
principally  carbonates  of  lime,  soda,  and  magnesia,  besides  traces 
of  other  materials,  and  considerable  free  carbonic-acid  gas. 

A  glass  of  Apollinaris  or  similar  water  taken  an   hour  after  a 


190 


STIMULANTS,   BEVERAGES.   CONDIMENTS. 


too  heavy  dinner  promotes  digestion  and  helps  remove  waste  prod- 
ucts from  the  system.  In  fevers  such  waters  are  always  useful,  and 
they  may  be  given  very  freely.  They  often  allay  nausea  and  vomit- 
ing. They  may  be  employed  for  the  dilution  of  liquors  and  milk 
for  invalids.  Some  persons  can  digest  milk  better  when  diluted  with 
Vichy,  carbonic-acid  water,  plain  soda  water,  or  Seltzer.  The  addi- 
tion of  the  latter  tends  to  overcome  the  constipation  which  milk  is 
apt  to  cause. 

Some  waters  are  sold  as  natural  lithia  waters,  but  the  quantity 
of  lithium  contained  in  any  spring  water  is  usually  very  minute, 
and  beverages  of  this  class  are  generally  re-enforced  artificially  by 
lithium  salts.  They  are  used  to  counteract  the  lithic-acid  di- 
athesis, gout,  and  rheumatism. 

Kronenquelle  water  is  an  alkaline  lithia  water  from  Obersalz- 
brunn,  in  Silesia,  which  contains  considerable  sodium  carbonate  and 
traces  of  iron  and  manganese. 

The  Buffalo,  Londonderry  (New  Hampshire),  and  other  lithia 
waters  are  much  prescribed  in  this  country. 

Below  is  given  a  list  of  some  of  the  more  noted  waters  which 
are  extensively  used  in  conjunction  with  dietetic  treatment: 

1.  Alkaline  Waters. — Vichy,  in  France;  Ems,  in  Germany; 
Fachingen,  in  Germany ;  Saratoga  Vichy  (rich  in  CO^),  New  York  ; 
St.  Louis  Springs,  Michigan  (poor  in  CO^) ;  Bethesda  Springs,  Wis- 
consin. 

Other  sodium  chloride  waters,  containing  also  some  carbonates 
and  COj,  are :  Hathorn  Spring,  in  Saratoga,  New  York  ;  Congress 
Spring,  in  Saratoga,  New  York ;  Kissengen  Spring,  in  Saratoga, 
New  York ;  Homburg,  in  Germany ;  Wiesbaden,  in  Germany  ;  Kis- 
sengen, in  Germany ;  Selters,  in  Germany  ;  Bourbonne,  in  France. 

The  alkaline  waters  all  contain  more  or  less  carbon  dioxide, 
and  their  most  important  ingredients  are  the  alkaline  carbonates. 

They  also  contain  sodium  chloride,  and  sometimes  sodium  sul- 
phate. Some  have  one  variety  of  salts,  some  another,  which  pre- 
ponderates. Generally  speaking,  the  European  waters  are  richer  in 
alkalies  than  are  the  American. 

Alkaline  waters  are  useful  in  the  uric-acid  diathesis  and  lithaemic 
conditions,  gout,  chronic  rheumatism,  obesity,  hepatic  engorgement, 
gallstones,  hyperacidity  of  the  gastric  juice,  gastric  ulcer,  and  ca- 
tarrhs of  the  mucous  membranes,  especially  of  the  stomach,  respira- 
tory tract,  and  bladder. 

2.  Alkaline  Sulphur  Waters. — Richfield  Springs,  in  New 
York ;  Sharon  Springs,  in  New  York  ;  Avon  Springs,  in  New  York ; 
Greenbrier  White  Sulphur  Springs,  in  West  Virginia ;  Harrogate,  in 
England;  Neuendorf,  in  Germany;  Meinberg,  in  Germany;  Aix-la- 
Chapelle,  in  Rhenish  Prussia. 


STIMULANTS   AND    BEVERAGES. 


191 


These  waters,  containing  sulphuretted  hydrogen  in  addition  to 
other  ingredients,  are  used  considerably  in  gout,  chronic  rheuma- 
tism, obesity,  and  chronic  eczema.  They  are  often  supplemented  by 
a  course  of  chalybeate  waters. 

Hot  springs  are  found  at  the  Hot  Sulphur  Springs  of  Arkansas 
and  Virginia,  and  Schlangenbad  and  Plombieres,  in  Europe. 

3.  Alkaline  and  Saline  Purges  contain  a  high  percentage  of 
sodium  and  magnesium  sulphates.  These  waters  are  often  called 
"  bitter  waters." 

Such  are:  Pullna,  in  Bohemia  (the  strongest  of  all,  and  one  of 
the  oldest  known) ;  Carlsbad  (Sprudel),  in  Bohemia ;  Marienbad 
(Kreuzbrunnen),  in  Bohemia;  Friedrichshall,  in  Germany;  Franz 
Josef,  in  Austria;  Kissengen  Bitterwater,  in  Bavaria;  Hunyadi 
Janos,  in  Hungary;  Rubinat  Condal  Spring,  in  Spain;  Villacabras, 
in  Spain;  Crab  Orchard,  in  Kentucky;  Estill  Springs,  in  Kentucky; 
Bedford  Springs,  in  Pennsylvania;  Epsom,  in  England;  some  of  the 
Saratoga  waters. 

These  waters  are  useful  to  counteract  indiscretions  in  diet  and 
the  overloading  of  the  liver. 

The  Rubinat  water  is  effective  and  possesses  the  advantage  of 
being  less  disagreeable  than  many  of  the  others. 

Villacabras  water  is  a  Spanish  sodium  sulphate,  strongly  purga- 
tive water,  obtained  not  far  from  Madrid. 

These  waters  should  be  taken  either  very  cold  or  in  a  half-pint 
of  very  hot  water.  If  drunk  lukewarm  their  taste  is  nauseous,  and 
may  excite  emesis. 

4.  Chalybeate  waters. — Schwalbach  (Stahlbrunnen),  Pyrmont 
(Neubrunnen)  Spa,  Belgium;  St.  Moritz,  Switzerland;  Rock  Enon, 
Virginia.  These  waters  serve  as  tonics  for  the  blood  and  nerves, 
but  if  too  long  used  they  cause  dyspepsia  and  anaemia. 

5.  Acidulous  waters  contain  CO,  in  excess,  and  but  very  little 
salts  of  any  kind.  Such  are  Clysmic  Spring,  in  Wisconsin;  Blue 
Lick,  in  Kentucky;  Carlsbad  (Dorotheenquelle),  in  Bohemia. 

6.  Various  waters  are  the  Alum  Springs,  in  Virginia;  Oak 
Orchard  Acid  Spring,  in  New  York ;  Bourbqule,  in  France,  which 
contains  arsenic.  Roncegno  water  is  a  ferruginous  arsenical  water 
from  the  Tyrolean  Province  of  Trent. 

Tannin. 

Tannin  is  an  astringent  of  vegetable  origin  which  exists  in  tea, 
coffee,  and  many  wines,  especially  the  red  wines,  and  as  such  it  is 
worthy  of  brief  separate  consideration.  It  possesses  no  nutrient 
power  whatever,  and  is  mainly  of  interest  to  the  dietetist  from  the 
harm  it  may  occasion  if  taken  too  freely.  In  strong  solution  it 
precipitates  the  ferment  of  the  gastric  juice  and  renders  it  inert, 
15 


192 


STIMULANTS,   BEVERAGES,   CONDIMENTS. 


and  also  gives  rise  to  constipation  by  its  astringency,  which  affects 
the  mucous  membrane  of  the  intestine.  For  these  reasons  strong 
tea  or  tea  drunk  to  excess  materially  hin  Jers  gastric  digestion. 

According  to  Fraser,  the  tannin  in  tea  interferes  with  the  diges- 
tion of  fresh  meat,  but  to  a  less  extent  with  that  of  dried  or  smoked 
meat,  such  as  tongue  or  ham,  the  fibres  of  which  are  already  shrunk- 
en by  curing. 

Coffee  contains  much  less  tannin  than  tea,  and  therefore  does 
not  have  the  same  effect  upon  the  alimentary  canal. 

Tannin  is  contained  in  red  wines  in  considerable  quantity,  h( 
clarets  are  mildly  astringent  and  constipating. 

Tannin  is  useful  for  a  variety  of  local  astringent  application^ 


h^A 


Tea.  ^V 

Method  of  Preparation. — Tea  is  a  preparation  made  from  the 
leaves  of  various  species  of  a  hardy  evergreen  shrub  called  TAea. 
The  manufacture  consists  in  plucking  the  young  leaves  of  the  plant 
and  placing  them  in  the  sun;  after  they  have  become  withered  they 
are  rolled  and  twisted.  This  process  is  sometimes  conducted  by 
hand,  or  even  by  the  feet  of  the  natives  in  China,  and  sometimes  by 
machinery.  The  leaves  are  next  pressed  into  small  masses  or  rolled 
into  balls  and  allowed  to  ferment  while  still  moist,  after  which  they 
are  dried  over  a  fire  of  a  temperature  sufficient  to  evaporate  all  the 
moisture.  They  are  finally  sifted  and  assorted  into  different  quali- 
ties. The  value  of  the  tea  depends  upon  its  flavour,  and  this  is 
mainly  influenced  by  the  process  of  fermentation,  which  must  be 
supervised  with  great  care. 

Green  and  Black  Tea. — The  distinction  between  black  and 
green  teas  is  due  to  the  variations  in  their  mode  of  preparation, 
and  not  to  separate  species  of  the  plant.  Green  tea  is  made  by 
steaming  the  leaves  before  they  are  rolled  and  dried.  The  further 
difference  between  green  and  black  tea  consists  in  the  relatively 
larger  quantity  of  astringent  material  (tannin)  which  predominates 
in  green  tea.  The  following  table,  from  an  analysis  by  Mr.  Y.  Kozai, 
illustrates  this  point  and  exhibits  the  proportionate  quantity  of  some 
of  the  more  important  ingredients  of  tea.  It  presents  the  difference 
in  percentage  composition  between  green  and  black  tea  prepared 
from  the  same  plant. 


Crude  protein  . 

Fibre.. 

Ash 

Theine 

Tannin 

Total  nitrogen 


Black  te:u 


STIMULANTS   AND   BEVERAGES. 


193 


Because  green  tea  contains  more  than  twice  as  much  of  the 
astringent  tannin  than  black  tea  it  is  generally  regarded  as  less 
wholesome  than  the  latter.  It  is  also  believed  to  have  a  somewhat 
less  stimulating  effect  upon  the  nervous  system,  though  this  can 
hardly  be  accounted  for  by  the  slight  variation  in  the  percentage  of 
theine  shown  to  exist  by  the  above  table,  this  latter  substance  being 
the  alkaloid,  which  is  chiefly  responsible  for  the  stimulating  influence 
of  tea  upon  the  nerves. 

There  has  been  some  discussion  in  regard  to  the  identity  of  theine 
with  caffeine,  and  by  many  writers  they  are  believed  to  be  the  same 
alkaloid.  Rice  says  that  most  of  the  commercial  caffeine  is  derived 
from  tea  leaves,  but  May  finds  that  in  frogs,  at  least,  "  theine  pro- 
duces spontaneous  spasms  and  convulsions,  while  caffeine  does  not. 
Theine  impairs  the  nasal  reflex  early  in  the  poisoning  process,  while 
caffeine  does  not,  if  at  all,  until  the  very  last  stage." 

Properties. — The  peculiar  stimulating  properties  which  tea  pos- 
sesses, as  well  as  its  colour  and  agreeable  flavour,  depend  upon  the 
season  of  the  year  at  which  the  leaves  are  gathered,  the  variety  of 
the  plant,  the  age  of  the  leaves,  which  naturally  become  tough  as 
they  grow  older,  and  the  care  exercised  in  their  preparation.  The 
flavour  is  produced  by  the  formation  of  volatile  oils  which  develop 
during  fermentation.  It  is  these  substances  which  cause  the  minor 
differences  in  effect  of  tea  and  coffee. 

The  aroma  as  well  as  the  flavour  of  tea  is  often  artificially  in- 
creased by  the  addition  of  such  substances  as  the  leaves  of  orange 
flowers,  jasmine,  or  roses. 

Tea  made  of  small  leaves  packs  closely,  and  if  measured  by  the 
spoonful  gives  a  stronger  beverage  than  the  coarser  grained  varieties. 

Infusion. — The  flavour  of  tea  depends  not  only  on  the  character 
of  the  leaves,  but  upon  that  of  the  water  which  is  added  to  them. 
About  five  grammes  of  leaves  should  be  used  for  one  infusion.  The 
water  should  be  poured  upon  the  tea  leaves  when  boiling,  and  the  in- 
fusion should  not  last  beyond  three  or  four  minutes  if  the  flavour  is 
to  be  delicate;  if  it  is  continued  beyond  this  point  materials  become 
extracted  from  the  leaves  which,  while  they  may  make  the  tea  ap- 
pear stronger,  materially  diminish  the  delicacy  of  its  flavour.  The 
water  should  be  neither  too  hard  nor  too  soft,  but  soft  water  extracts 
more  of  the  soluble  materials  of  the  leaves  and  yields  a  beverage  of 
darker  colour.  Water  which  contains  iron  or  lime  salts  should  be 
boiled  with  sodium  carbonate  before  it  is  used  for  tea  infusion. 

PHYSIOLOGICAL  AND  THERAPEUTIC  ACTION. 
Good  Effects. — Tea  is  mildly  stimulating  to  the  nervous  system 
and  tends  to  increase  the  activity  of  certain  vital  functions.     It  is  re- 
freshing and  relieves  bodily  fatigue.     For  the  latter  purpose  it  has 


194 


STIMULANTS.   BEVERAGES,   CONDIMENTS. 


been  found  especially  useful  for  soldiers  on  the  march  in  hot  cli- 
mates. 

Captain  Woodruff,  U.  S.  Army,  says :  "  The  universal  experience 
of  military  men  testifies  to  the  absolute  necessity  of  tea  or  coffee. 
The  latter  is  generally  preferred,  but  the  writer's  experience  points' 
to  tea  as  preferable  in  the  long  run."  For  this  purpose  both  these 
substances  are  better  preserved  if  compressed  into  small  bulk. 

In  some  persons  a  cup  of  hot  tea  affords  prompt  and  decided  re- 
lief from  headache,  and  when  taken  quite  strong  it  is  sometimes  serv- 
iceable in  the  cure  of  chronic  alcoholism.  It  is  also  used  as  an 
antidote  for  opium  poisoning,  but  coffee  is  preferable. 

The  "strength  "  of  tea  as  applied  to  the  appreciation  of  its  taste 
in  distinction  from  its  effect  on  the  nerves  is  due  to  the  quantity  of 
tannin  present,  which  is  bitter.  A  bitter  tea  is  not  therefore  neces- 
sarily a  strong  one  in  its  stimulating  properties,  which  are  owing  to 
the  theine. 

Tea,  when  employed  as  a  beverage,  possesses  some  effects  which 
are  not  strictly  due  to  action  upon  the  nerves.  It  introduces  con- 
siderable hot  water  into  the  system,  which  is  beneficial  when  taken  at 
the  proper  time  in  relation  to  meals,  and  when  milk  or  cream  and 
sugar  are  added  its  nutritive  value  becomes  considerable.  Tea  is 
moderately  sudorific  in  action,  and  it  has  a  slight  influence  in  regulat- 
ing the  circulation  and  temperature  of  the  body,  which,  if  too  cold, 
becomes  warm  by  the  stimulating  effect  upon  the  heart,  whereas  if 
the  body  is  too  hot,  tea  may  exert  a  cooling  influence  by  increasing 
perspiration  and  evaporation  from  the  surface.  Hot  tea  will  some- 
times increase  the  action  of  aperients,  but  it  is  doubtful  whether  it 
has  any  more  effect  than  a  similar  quantity  of  hot  water. 

Roberts  gives  the  following  analysis  of 

The  Effects  of  Tea  and  Coffee  on  Gastric  Digestion. 

Digesting  mixture:  2  grammes  of  dried  beef  fibre,  0.15  c.  c.  hydrochloric  acid,  i  c.  c. 
glycerin  extract  of  pepsin,  varying  proportions  of  tea  and  coffee,  water  to  100  c.  c. 


TIME   IN   WHICH    DIGESTION   WAS   COMPLETED. 
(normal.    100   MINUTES.) 

TAINED  IN  THE  DIGESTING  MiXTURE. 

Tea,  5-per-cent 
strength. 

Coffee,  5-per-cent 
strength. 

Coffee,  15-per-cent 
strength. 

10  per  cent 

105  minutes. 
140        " 
180 
Embarrassed. 

105  minutes. 
140        " 
180 
Embarrassed. 

160  minutes. 

20  "      "    

40  "       "    

60  "      "    

Many  elderly  people  find  tea  particularly  grateful  and  soothing 
after  reaching  a  period  of  life  when  the  functional  activity  of  the 
stomach  is  gradually  weakened.  A  disproportion  may  exist  between 
the  quantity  of  food  which  the  stomach  can  digest  and  the  actual 


STIMULANTS   AND   BEVERAGES. 


195 


need  of  the  body  for  nutritive  materials  to  counterbalance  the  daily 
waste.  In  such  cases  tea  enables  the  aged  poor  to  live  on  less  food 
than  they  would  otherwise  require,  and  is  thus  economical  for  them. 

The  refreshing  effect  of  tea  when  taken  into  an  empty  stomach 
after  bodily  fatigue  may  continue  between  three  and  four  hours,  a 
period  considerably  longer  than  that  of  coffee  or  light  wine. 

A  cup  of  hot  green  or  black  tea  is  a  good  diaphoretic  for  bron- 
chitis. It  is  also  a  diuretic  for  many  persons  if  taken  into  an  empty 
stomach. 

Ill  Effects. — The  ill  effects  of  excessive  tea  drinking  are  refera- 
ble to  its  action  on  the  digestive  and  nervous  systems.  If  taken  in 
large  quantities  with  meals,  tea  precipitates  the  digestive  ferments, 
retards  the  activity  of  digestion,  and  may  even  occasion  gastric  irri- 
tation and  catarrh.  Constipation  usually  results,  though  there  is 
sometimes  diarrhoea,  and  more  or  less  flatulency.  The  latter  may 
itself  cause  insomnia.  The  effect  on  the  nervous  system  is  to  over- 
stimulate  it  by  first  producing  restlessness  and  insomnia,  and  finally 
muscular  tremors,  palpitation,  and  increased  nervous  worry.  Per- 
sons who  are  subjected  to  some  unusual  strain  or  anxiety  find  that 
tea  for  the  time  being  disagrees  with  them,  whereas  they  are  able  to 
drink  it  regularly  when  in  ordinary  health.  Cheap  teas  are  always 
much  more  apt  to  produce  ill  effects  than  the  more  expensive  varieties. 

Indian  teas  contain  a  larger  proportion  of  tannin  than  do  those 
from  China.  For  this  reason  they  are  more  likely  to  produce  disor- 
ders of  digestion  and  constipation.  They  also  occasion  nervousness 
and  sleeplessness  to  a  marked  degree  when  drunk  in  excess. 

The  ill  effects  of  poor  tea  and  of  tea  rich  in  tannin  can  be  over- 
come in  some  degree,  as  suggested  by  Roberts,  by  the  addition  of 
carbonate  of  sodium  in  the  proportion  of  ten  grains  to  the  ounce  of 
dried  tea  leaves;  this  does  not  materially  interfere  with  the  taste. 

When  tea  taken  with  milk  and  sugar  is  found  to  disagree,  the 
added  juice  of  a  slice  or  two  of  lemon  makes  it  acceptable  and  bene- 
ficial to  many  persons.  Tea  which  is  "  steeped  "  is  more  unwhole- 
some on  account  of  the  extra  tannin,  etc.,  which  is  extracted. 

Tea  must  be  avoided  in  dyspepsia,  gastric  irritability  from  any 
cause,  constipation,  insomnia,  and  "  nervousness,"  and  usually  in  gas- 
tric catarrh;  although  so  good  an  authority  as  Bauer  recommends 
weak  tea  as  less  apt  than  coffee  to  induce  heartburn  or  aggravate  di- 
arrhoea. 

An  unusual  case  of  multiple  neuritis  caused  by  drinking  between 
two  and  three  pints  daily  of  strong  tea  is  reported  by  Spratling  (New 
York  Medical  Record,  July  28,  1894). 

In  a  recent  report  upon  insanity  in  Ireland  tea  is  mentioned  as  a 
contributing  factor.  A  very  poor  quality  is  there  used,  and  it  is  often 
stewed  nearly  all  day,  water  being  added  from  time  to  time.     This 


iq6  stimulants,  beverages,  condiments. 

report  continues:  "Undoubtedly  the  method  of  preparation  adopted 
and  the  excessive  use  of  this  article  of  diet,  now  so  general  among 
our  poorer  population,  tends  to  the  production  of  dyspepsia,  which 
in  its  turn  leads  to  states  of  mental  depression  highly  favourable  to 
the  production  of  various  forms  of  neurotic  disturbance." 

Adulteration  of  Tea. — The  adulteration  of  tea  is  extensively 
practised,  but  it  can  rarely  be  said  to  be  injurious  to  the  digestion, 
for  the  adulterants  are  either  added  in  very  minute  proportion,  as  in 
the  case  of  plumbago,  indigo,  or  Prussian  blue,  for  the  purpose  of 
colouring  or  "facing  "  the  tea,  or  foreign  leaves  are  mixed  with  the 
tea,  which  simply  dilute  it  without  necessarily  making  it  injurious. 
Green  tea  is  more  apt  than  black  to  be  adulterated.  Catechu  as  well 
as  salts  of  iron  are  sometimes  added  to  increase  the  astringency. 

Quantity  Consumed. — It  is  interesting  to  make  a  comparison 
between  the  consumption  of  tea  and  coffee  in  the  United  States, 
and  the  following  figures,  which  have  been  obtained  from  the 
United  States  Treasury  and  are  quoted  by  H.  W.  Wiley,  Chief 
Chemist  of  the  United  States  Department  of  Agriculture,  are  instruc- 
tive in  this  respect.  The  quantity  of  tea  consumed  in  the  United 
States  in  1890  was  83,494,956  pounds,  while  the  consumption  of  coffee 
during  the  same  period  was  490,181,755  pounds.  The  amount  of  tea 
consumed  per  capita  in  the  United  States  is  1.33  pounds,  while  the 
amount  of  coffee  consumed  is  7.8  pounds.  Slightly  more  than  half 
of  the  tea  drunk  in  the  United  States  comes  from  China,  and  a 
large  part  of  the  remainder  from  Japan.  The  India  teas  are  nearly 
twice  as  strong  as  the  others,  but  they  are  much  less  commonly 
drunk  in  this  country  excepting  in  mixtures  where  they  have  been 
added  to  Chinese  or  Japanese  teas  to  improve  their  flavour  and 
strength. 

Coffee. 

Composition. — Coffee  consists  of  the  berries  or  seeds  of  Coffea 
arabica,  which  are  dried,  roasted,  ground,  and  subjected  to  infusion. 
The  coffee  drunk  in  the  United  States  is  mainly  imported  from 
South  and  Central  America,  Mexico,  and  Java,  63  per  cent  being 
imported  from  Brazil.  The  Rio  berry  is  smaller  than  that  from 
Java.  The  composition  of  coffee  beans  varies  somewhat,  but  an 
approximate  idea  of  it  is  obtained  from  the  following  table  from 
Konig,  which  gives  the  percentage  of  the  important  ingredients : 

Water i-i5 

Fat 14.48 

Crude  fibre 19.89 

Ash 4.75 

Caflfeine i .  24 

Albuminoids 13.98 

Other  nitrogenous  matter 45 .09 

Sugar,  gum,  and  dextrin i .  66 


STIMULANTS   AND    BEVERAGES. 


}9X 


The  coffee  berry  contains  no  starch,  and  Wiley  has  shown  that 
its  principal  carbohydrate  is  cane  sugar  or  sucrose  (United  States 
Department  of  Agriculture,  Bulletin  No.  13,  1892).  There  are  pres- 
ent also  a  substance  allied  to  dextrin  and  a  reducing  sugar.  The 
well-known  stimulant  effect  of  coffee  upon  the  nervous  system  is 
mainly  due  to  the  alkaloid  caffeine,  which  is  chemically  identical 
with  theine  and  possesses  the  same  physiological  properties,  its 
action  being  chiefly  upon  the  nerves  and  kidneys.  Coffee  also  con- 
tains a  little  aromatic  oil  which  is  moderately  stimulating  to  the 
nervous  system.     It  has  less  oil  than  tea. 

Method  of  Preparation. — The  preparation  which  the  coffee 
beans  require  consists  of  drying  them  by  roasting  at  a  temperature 
of  fully  200°  C,  after  which  they  are  ground  into  small  fragments  to 
facilitate  the  solution  of  their  ingredients  by  hot  water.  The  heat 
converts  the  sugar  of  the  beans  into  caramel  and  develops  vola- 
tile and  aromatic  substances  to  which  the  agreeable  aroma  of  the 
coffee  is  due.  Since  these  substances  are  volatile,  the  aroma  soon 
forsakes  the  beans,  and  they  should  not  be  roasted  or  ground 
long  before  they  are  to  be  used.  The  roasting  also  liberates  gases 
in  the  beans,  which  cause  them  to  increase  in  bulk  while  losing  in 
weight. 

The  methods  of  preparing  coffee  as  a  beverage  are  three — namely, 
(i)  filtration,  (2)  infusion,  and  (3)  decoction  or  boiling. 

(i)  In  filtration  boiling  water  is  allowed  to  percolate  slowly 
through  finely  ground  coffee.  Air  should  be  excluded  as  much  as 
possible  during  the  process  ;  otherwise  the  oxygen  alters  the  aroma. 
According  to  von  Liebig,  filtration  only  dissolves  from  11  to  15  per 
cent  of  the  coffee  instead  of  20  or  21  per  cent,  which  is  obtainable 
by  other  means. 

(2)  Infusion  is  the  common  mode  of  preparation  of  coffee  em- 
ployed in  this  country  and  in  Europe.  It  is  said  to  reduce  the  ex- 
citing influence  of  strong  coffee  without  destroying  its  aroma  or 
otherwise  altering  it.  In  conducting  this  process  the  finely  ground 
coffee  is  put  into  water  previously  boiled,  but  removed  from  the 
fire,  and  allowed  to  stand  for  about  ten  minutes  at  a  temperature  of 
180°  or  190°  F. 

(3)  Decoction  is  the  method  principally  used  in  Turkey  and  else- 
where in  the  East.  The  coffee  beans  are  ground  to  powder  and 
placed  in  cold  water,  which  is  then  heated  to  boiling.  The  beverage 
is  drunk  without  straining.  If  boiled  but  a  few  minutes  some  aroma 
still  remains,  but  it  is  soon  driven  off,  and  continued  boiling  extracts 
more  caffeine  than  is  obtainable  by  infusion. 

Coffee  long  boiled  or  left  standing  in  the  coffee  pot  over  the  fire, 
as  in  the  case  of  tea,  becomes  more  and  more  indigestible  from 
extraction  of  tannin. 


iqS  stimulants,  beverages,  condiments. 

Soft  water  extracts  more  coffee  from  the  berries  than  hard,  as 
it  does  from  tea  leaves. 

Coffee  should  always  be  made  from  newly  roasted  and  ground 
beans ;  and  when  economy  is  to  be  considered,  or  when  strength  and 
aroma  are  both  desired,  a  larger  proportion  of  the  soluble  ingredients 
may  be  obtained  by  combining  the  second  and  third  processes,  as 
described  by  Yeo :  "  After  first  preparing  an  infusion  by  passing 
boiling  water  over  the  coffee,  the  grounds  left  should  be  boiled  in 
more  water,  and  the  boiling  decoction  thus  obtained  should  be 
poured  over  another  portion  of  freshly  ground  coffee;  this,  in  turn, 
is  also  boiled  with  more  water,  to  be  used  again  with  fresh  coffee  in 
the  same  manner,  and  so  on.  By  this  method  all  the  soluble  matters 
in  the  coffee  are  extracted  and  none  of  the  aroma  is  needlessly  dis- 
sipated." Ready-made  coffee  is  sometimes  preserved  with  condensed 
milk  and  sugar  in  tin  cans.  This  preparation  merely  requires  to  be 
put  into  a  cup  of  hot  water  to  be  fit  for  drinking. 

PHYSIOLOGICAL   ACTION. 

Good  Effects. — Coffee,  when  taken  as  a  beverage,  has  well- 
marked  physiological  effects,  chiefly  upon  the  muscular,  vascular,  and 
nervous  systems.  It  removes  the  sensation  of  fatigue  in  the  mus- 
cles and  increases  their  functional  activity ;  it  allays  hunger  to  a 
limited  extent;  it  strengthens  the  heart  action,  and  constitutes  a 
valuable  cardiac  stimulant  in  some  forms  of  collapse  by  its  moderate 
quickening  effect  upon  the  pulse  and  influence  upon  the  vascular 
tone;  it  acts  as  a  diuretic,  and  increases  the  excretion  of  urea;  it 
has  a  mildly  sudorific  influence;  it  counteracts  nervous  exhaustion 
and  stimulates  nerve  centres.  It  is  used  sometimes  as  a  nervine  in 
cases  of  migraine,  and  there  are  many  persons  who  can  sustain  pro- 
longed mental  fatigue  and  strain  from  anxiety  and  worry  much 
better  by  the  use  of  strong  black  coffee.  In  low  delirium,  or  when 
the  nervous  system  is  overcome  by  the  use  of  narcotics  as  in  the 
case  of  opium  poisoning,  or  by  alcohol,  or  by  excessive  haemorrhage, 
strong  black  coffee  is  serviceable  to  keep  the  patient  from  falling 
into  the  drowsiness  which  soon  emerges  into  coma. 

Drunk  in  moderation,  coffee  is  a  mild  stimulant  to  gastric  diges- 
tion. In  the  bowels  coffee  has  an  opposite  effect  to  that  of  tea,  for 
it  stimulates  peristalsis,  and  for  many  people,  when  drunk  early  in 
the  morning,  it  possesses  a  distinctly  laxative  eft'ect.  It  thus  in- 
directly benefits  the  liver. 

Strong  coffee  with  a  little  lemon  juice  or  brandy  is  often  useful 
in  overcoming  a  malarial  chill. 

It  is  the  universal  testimony  of  army  officers  that  coffee  is  indis- 
pensable for  troops  in  active  service  to  relieve  fatigue  and  improve 
their  spirits. 


STIMULANTS   AND   BEVERAGES.  Iqq 

The  stimulating  and  diuretic  effect  of  coffee  is  more  decided 
when  it  is  taken  upon  an  empty  stomach. 

The  nutrient  value  of  coffee  alone  is  too  slight  to  be  considered, 
but  the  addition  of  sugar  and  milk,  as  in  the  case  of  tea,  makes  it  a 
valuable  food.  It  does,  however,  possess  some  effect  in  diminishing 
tissue  waste.  The  very  general  fondness  which  exists  for  the  taste 
of  coffee  makes  it  a  useful  means  of  flavouring  many  kinds  of 
foods  for  invalids,  such  as  jellies,  custards,  etc.  When  the  taste 
of  milk  is  objected  to,  the  addition  of  a  very  little  coffee  will  often 
overcome  the  dislike  for  it. 

Coffee  is  a  useful  cardiac  stimulant  for  children  who  are  suffering 
collapse  from  any  cause. 

Ill  Effects. — Strong  black  coffee  taken  after  dinner  tends  to  re- 
tard the  digestive  processes  somewhat,  and  for  this  reason  it  should 
be  avoided  by  dyspeptics;  but  to  persons  with  sourfd  digestion  who, 
perhaps,  have  eaten  rather  more  food  than  they  need,  this  influence 
may  not  prove  a  disadvantage,  and  meanwhile  its  stimulating  effect 
may  arouse  the  overtaxed  digestive  functions. 

Many  persons  find  themselves  able  to  perform  much  more  active 
brain  work  by  the  stimulus  afforded  by  drinking  coffee  and  strong 
tea.  If  one  is  obliged  to  work  late  by  night  at  severe  mental 
labour,  sleepiness  may  be  avoided  by  this  means.  The  continuance 
of  this  practice,  however,  soon  results  in  forming  a  coffee  or  tea 
habit,  in  which  the  individual  becomes  a  slave  to  the  beverage  and 
feels  an  imperative  need  for  it  at  certain  hours  of  the  day,  when,  if 
it  cannot  be  obtained,  the  system  suffers  from  languor,  prostration 
or  restlessness,  and  craving.  By  drinking  two  or  three  cups  of 
strong  black  coffee  at  every  meal  muscular  tremors  sometimes  are 
developed  with  "nervousness,"  anxiety,  dread  of  impending  ill,  with 
palpitation  and  feeling  of  precordial  oppression,  heartburn,  dyspep- 
sia, and  insomnia.  In  such  cases  the  symptoms  usually  promptly 
subside  on  suspending  or  restricting  the  beverage;  but  if  they  have 
been  long  continued,  the  use  of  sedatives  may  be  necessary  to  con- 
trol the  ill  effects.  Extreme  cases  suggest  the  condition  resulting 
from  some  drug  habits,  and  the  amount  of  caffeine  consumed  pro- 
duces great  irritability  of  the  whole  nervous  system  and  may  even 
overexcite  the  mind.  In  the  lower  animals  caffeine  has  been  known 
to  cause  paralysis.  Those  who  are  habituated  to  either  immoderate 
tea  or  coffee  drinking  do  well  to  stop  the  habit  abruptly  in  order  to 
observe  the  degree  of  craving  which  results  and  the  influence  which 
these  beverages  is  acquiring  over  the  system. 

Quantity  Consumed. — In  connection  with  the  comments  often 
made  in  regard  to  the  nervousness  of  temperament  \^hich  character- 
ises many  Americans,  it  is  not  without  interest  to  note  a  fact  which 
may  stand  m  the  relation  of  either  cause  or  effect  to  this  condition — 


200  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

namely,  that  the  people  of  the  United  States  consume  one  third  of 
the  total  coffee  produced,  or  more  than  Germany,  Austria,  Hungary,. 
France,  and  the  United  Kingdom  combined.  On  the  other  hand, 
England  and  her  colonies  consume  one  half  of  the  world's  output  of 
tea,  and  the  United  States  consumes  but  one  fifth  of  it. 

Adulteration. — The  adulteration  of  coffee,  more  particularly 
when  it  is  ground,  is  so  easily  accomplished  that  it  affords  great 
temptation  to  unscrupulous  dealers.  Almost  all  ground  coffee  sold 
to  the  poor  is  adulterated,  but  the  adulterants  are  not  usually  of  a 
character  to  render  them  injurious  to  health.  Chief  among  them  is 
chicory,  which  is  added  both  for  dilution  and  for  its  influence  on 
the  colour  and  flavour  of  the  coffee.  This  substance,  however,  is 
actually  preferred  by  many  persons,  and,  as  it  is  in  no  wise  injurious, 
it  is  hardly  fair  to  consider  it  as  an  adulterant  when  its  admixture 
with  coffee  is  acknowledged. 

Chicory  is  prepared  from  the  root  of  the  chicory  plant,  or  wild 
endive,  which  is  roasted  and  ground.  By  roasting,  an  aroma  is  de- 
veloped, as  in  the  case  of  the  coffee  berry.  Chicory  contains  no 
caffeine,  but  it  holds  a  volatile  oil  and  a  bitter  principle. 

Its  admixture  with  coffee  is  detected  by  bleaching  with  chlo- 
rinated soda,  which  acts  promptly  on  the  pigments  of  chicory,  but 
very  slowly  on  those  of  the  natural  coffee. 

In  France,  coffee  is  frequently  flavoured  with  caramel  instead  of 
chicory,  which  is  more  extensively  used  in  England  and  the  United 
States. 

Coffee  is  also  diluted  with  various  substances,  such  as  peas,  beans, 
peanuts,  and  ground  acorns  or  date  stones  are  sometimes  used. 

Imitation  coffees  are  composed  of  pellets  of  roasted  wheat  flour, 
or  sometimes  wheat  flour  and  chicory,  or  even  sawdust.  Rye,  corn, 
and  barley  are  also  mingled  with  wheat  for  the  same  purpose. 

Fat  globules  are  always  present  in  impure  coffee  in  consider- 
able quantity.  The  substitutes  for  coffee  are  easily  detected  by  the 
fact  that,  unlike  the  true  coffee  bean,  which,  unless  overroasted, 
floats  after  roasting,  they  usually  sink  to  the  bottom  of  a  glass  of 
water. 

Colouring  matter,  like  ochre,  burnt  umber,  charcoal,  Prussian  blue, 
and  lead  chromate,  is  added  occasionally  before  the  roasting,  as  well 
as  burned  sugar  and  sirups,  in  order  to  affect  the  appearance  and 
color  of  the  beans.  The  beans  are  sometimes  polished  in  cylinders, 
in  which  they  are  made  to  revolve  with  soapstone. 

Substitute  for  Coffee. — A  substitute  for  coffee  may  be  made 
from  wheat,  rye,  or  oatmeal  to  which  butter  is  added  in  the  propor- 
tion of  one  part  to  eight  of  meal.  The  butter  is  melted  in  a  hot  iron 
frying  pan  and  the  meal  is  sprinkled  over  it  and  briskly  stirred  with- 
out burning.     Thus  prepared,  the  meal  resembles  roasted  coffee,  and 


STIMULANTS   AND   BEVERAGES.  20I 

when  half  an  ounce  is  boiled  in  a  pint  of  water  it  makes  a  beverage 
which  is  rather  agreeable  in  taste.  In  Bavaria  this  substitute  for 
coffee  is  used  largeh'  by  the  peasants,  and  it  is  also  supplied  in  some 
charitable  institutions  in  this  country.  Its  use  necessitates  boiling 
the  water,  which,  if  it  contains  any  impurities,  is  thus  rendered  harm- 
less. 

Mate\  called  also  Paraguay  tea,  is  manufactured  from  the  dried 
leaves  of  a  plant  resembling  holly.  It  is  a  mildly  stimulating  bever- 
age which  contains  theine,  but  it  has  no  special  dietetic  advantages 
over  tea  or  coffee. 

Relative  Value  of  Coffee  and  Tea. — Much  argument  has  been 
expended  on  the  relative  digestibility  and  usefulness  of  tea  and  coffee, 
but  about  all  that  can  be  said  definitely  in  regard  to  the  matter  is, 
that  many  persons  who  can  drink  tea  with  impunity  are  made  nerv- 
ous and  are  kept  awake  by  a  similar  quantity  of  coffee,  whereas 
there  are  others  who  find  that  coffee  aids  their  digestion  while  tea  in- 
terferes with  it,  and  that  it  affects  them  in  every  way  more  agreeably 
than  tea  ;  and  still  a  third  class  cannot  take  either  tea  or  coffee 
without  producing  indigestion,  insomnia,  and  nervousness.  Speak- 
ing very  generally,  coffee  is  believed  in  the  United  States  to  be 
more  digestible  and  useful  than  tea,  but  in  other  parts  of  the  world, 
especially  in  England,  China,  and  India,  tea  is  regarded  as  more 
beneficial  than  coffee.  In  equal  weight,  tea  contains  more  than 
twice  as  much  caffeine  or,  as  it  is  also  called,  theine.  In  this 
country,  however,  it  is  customary  to  use  about  50  per  cent  more  of 
coffee  than  of  tea  to  the  same  quantity  of  water. 

Coffee  is  said  to  irritate  the  mucous  membrane  of  the  stomach 
less  than  tea  when  drunk  in  very  large  quantities. 

It  has  a  more  decided  stimulant  action  than  tea  upon  both  the 
force  and  frequency  of  the  pulse. 

Cocoa. 

Cocoa  and  chocolate  are  both  prepared  from  the  cocoa  bean,  or 
pulpy  seeds  of  the  exotic  cacao  tree,  Theobroma  cacao.  The  major 
portion  of  the  supply  consumed  in  the  United  States  is  derived 
from  Brazil,  the  British  West  Indies,  Ecuador,  Venezuela,  and  Dutch 
Guiana.  In  the  United  States  in  189c  the  consumption  of  choco- 
late amounted  to  634,551  pounds,  and  of  cocoa  to  993,402  pounds. 

The  cacao  tree  attains  a  height  varying  up  to  twelve  metres. 
It  blossoms  frequently  and  yields  two  crops  a  year  of  a  bright- 
yellow  soft  fruit.  The  fruit,  which  bears  some  resemblance  to  a 
small  cucumber,  contains  two  or  three  dozen  colourless  seeds 
embedded  in  mucilaginous  material.  When  dried  in  the  sunlight, 
the  seeds  acquire  a  bright-yellow  or  brown  colour  and  harden. 
The  cocoa  starch  grains  are  spherical. 


202  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

Preparation. — Cocoa  may  be  either  fermented  or  unfermented. 
The  former  variety  is  dried  in  the  sun  at  once,  and  the  latter  is 
kept  for  some  time,  in  quantity,  in  a  cool,  moist  place,  while  fermen- 
tation proceeds.  The  process  of  fermentation  greatly  improves  the 
flavour,  for  the  natural  acidity  and  bitter  taste  of  the  seeds  suc- 
ceeds to  a  milder,  somewhat  aromatic,  and  more  agreeable  flavour. 

The  husks  of  the  cocoa  beans  are  irritant  to  the  alimentary 
canal,  and  possess  little  nutrient  material. 

The  kernels  when  finely  ground  constitute  "  cocoa  nibs,"  from 
which  a  decoction  is  made  by  boiling  in  water  for  about  two  hours, 
and  removing  the  insoluble  residue  by  straining  or  decanting ;  but 
the  cocoa  usually  sold  in  market  is  made  by  grinding  the  kernels 
into  a  paste,  to  which  starch  or  sugar  is  added.  If  starch  has  been 
used,  the  cocoa  must  be  boiled  for  some  minutes,  but  if  diluted 
with  sugar  it  is  only  necessary  to  mix  it  with  boiling  water  or 
milk. 

The  different  preparations  of  cocoa  are  very  numerous,  but  the 
quantity  commonly  used  for  making  a  single  cup  of  the  beverage  is 
a  heaping  teaspoonful  or  more. 

Composition — The  cocoa  beans,  after  being  husked  and  dried, 
contain  fat  and  theobromine,  besides  a  little  albumin,  starch,  pig- 
ment and  salts. 

The  average  percentage  of  the  principal  ingredients  of  cocoa 
prepared  for  a  beverage  is  shown  in  the  following  analysis  by  Stiit- 
zer  of  a  specimen  of  Holland  cocoa: 

Theobromine i  •  73 

Total  nitrogenous  substances 19 .  88 

Fat 30.51 

"Water 3.83 

Ash 8 .  30 

Fibre  and  non-nitrogenous  extract 37-48 

Theobromine  is  the  principal  alkaloid  of  cocoa,  and  is  almost 
identical,  both  chemically  and  in  its  physiological  effect,  with 
cafi^eine. 

Cacao  Butter. — The  fat,  which  is  called  cacao  butter,  is  the 
nutrient  ingredient  of  most  importance.  It  usually  constitutes  50 
per  cent  of  the  cocoa  bean.  It  has  an  agreeable  taste  and  odour, 
and  it  may  be  kept  indefinitely  without  change.  Because  it  melts 
readily  at  low  temperatures,  it  is  quickly  dissolved  in  the  alimen- 
tary canal,  and  it  is  used  by  itself  for  making  suppositories. 

Uses. — Cocoa  is  not  as  digestible  as  is  generally  supposed 
because  it  leaves  a  large  residue  of  unabsorbed  material  from  the 
nitrogenous  ingredients,  and  its  relative  deficiency  in  starches  and 
salts  prevents  it  from  being  regarded  as  a  "  complete  "  food. 
Whatever  nutritive  power  cocoa  possesses  depends  upon  its  fat  and  a 


STIMULANTS   AND   BEVERAGES. 


203 


small  percentage  of  digestible  albumin.  If  the  cocoa  is  roasted  by 
too  high  a  temperature,  the  latter  is  destroyed. 

The  term  "  soluble  cocoa  "  is  erroneous,  because  neither  the  fat 
nor  much  of  the  albuminous  material  is  truly  soluble,  and  if  they 
are  removed  the  food  value  of  the  cocoa  preparation  is  much 
impaired.  These  substances  may,  however,  be  reduced  to  a  fine 
state  of  subdivision  and  held  in  suspension,  but  the  cocoa  bean 
contains  so  much  fat  that  it  cannot  be  powdered  unless  the  fat  is 
removed  by  artificial  process  or  diluted  with  sugar  or  some  form  of 
starch.  The  various  powders  recommended  for  invalid  diet,  and 
which  are  sold  as  cocoa  or  broma,  under  different  proprietary 
names,  are  made  in  this  manner.  They  possess  rather  less  strength 
than  chocolate,  but,  on  the  other  hand,  since  they  contain  less  fat, 
they  rtiay  be  better  borne  by  an  enfeebled  stomach.  The  Holland 
cocoa  and  other  preparations  are  made  with  the  object  of  obtain- 
ing a  digestible  cocoa  without  removal  of  the  fat,  which  for  this  pur- 
pose is  saponified  by  the  use  of  sodium  and  potassium  hydrate  and 
magnesia.  These  alkaline  substances,  while  they  may  be  beneficial 
in  some  forms  of  dyspepsia,  in  other  cases  tend  to  interfere  with 
digestion  by  neutralising  the  gastric  juice. 

Both  cocoa  and  chocolate  differ  from  tea  and  coffee  in  the 
fact  that  besides  making  an  agreeable  and  very  slightly  stimu- 
lating drink,  they  contain  more  food  substance.  Their  actual  use 
for  this  purpose,  however,  is  exaggerated.  Cocoa  further  differs 
from  tea  and  coffee  in  that  the  insoluble  material  is  consumed  as 
well  as  the  soluble. 

Various  cocoa  powders,  essences,  etc.,  are  sold  for  use  for  infants, 
a  teaspoonful  of  which  may  be  dissolved  in  a  half  pint  of  hot  water. 
Or  an  infusion  of  cocoa  nibs  may  be  made.  Such  preparations  should 
never  be  given  to  very  young  infants,  and  as  a  rule  it  is  best  not  to 
allow  their  use  before  the  completion  of  the  third  year,  but  for  young 
growing  children  after  that  age  they  afford  an  excellent  beverage. 

After  suspension  in  hot  water  cocoa  is  apt  to  exhibit  a  scum  of 
fat  floating  upon  the  surface  of  the  cup.  This  may  be  skimmed  off 
on  a  piece  of  bread  or  cracker  and  eaten  in  lieu  of  butter — a  practice 
common  among  the  Italians.  Cocoa,  on  account  of  its  large  percent- 
age of  fat  in  comparison  with  starchy  ingredients,  forms  a  very  good 
addition  to  a  vegetarian  diet. 

Adulteration. — The  sophistication  of  cocoa  is  very  easy  of  ac- 
complishment as  well  as  profitable.  It  is  principally  done  with  sug- 
ars, starches,  and  fats.  Iron  salts  and  other  colouring  matters  are 
often  added.  These  adulterations  are  fraudulent,  but  not  necessarily 
harmful. 


204  stimulants,  beverages,  condiments. 

Chocolate. 

Preparation. — Chocolate  is  manufactured  from  the  husked, 
dried,  ground,  and  fermented  cocoa  seeds,  which  are  then  roasted  and 
made  into  paste  and  compressed  into  cakes  by  moderate  pressure. 
To  increase  the  flavour  and  nutrient  power  of  the  cakes  more  or  less 
sugar  (but  at  least  50  per  cent)  is  added,  and  various  flavouring  ex- 
tracts, such  as  vanilla,  etc.,  or  spices,  are  mixed  with  the  paste  before 
compressing  it. 

The  husks  of  the  seeds  are  separately  sold,  and  are  used  for  adul- 
teration in  making  cheaper  varieties  of  chocolate.  They  are  very 
inferior  to  the  seeds  in  all  their  properties. 

Uses. — The  value  of  chocolate  as  a  concentrated  food — aside 
from  the  sugar  which  it  contains — is  somewhat  overrated,  but  in  con- 
nection with  abundant  sugar  and  milk  it  is  very  nutritious.  Like 
cocoa,  if  pure  and  carefully  prepared,  its  ingredients  are  easily  di- 
gested and  absorbed.  In  cases  of  dyspepsia  and  various  gastric  dis- 
orders it  forms  an  agreeable  and  wholesome  drink,  and  it  enables 
the  patient  to  take  additional  nourishment  in  the  form  of  the  milk 
and  sugar  mixed  with  it.  It  is  also  mildly  stimulating  and  exhila- 
rating to  the  nervous  system  when  exhausted  through  overwork  or 
worry,  and  it  possesses  the  advantage  over  tea  and  coffee  that  it  does 
not  produce  wakefulness.  The  free  use  of  chocolate,  either  eaten  or 
drunk  as  a  beverage,  constituting  what  almost  might  be  called  a 
"chocolate  habit,"  is  not  injurious  to  the  nervous  system  after  the 
manner  of  overindulgence  in  tea  and  coffee,  but  it  produces  more  or 
less  gastric  dyspepsia  on  account  of  the  large  quantity  of  sugar  which 
it  already  contains  or  which  is  added  to  it  when  drunk. 

Chocolate  made  into  compressed  cakes  forms  a  convenient  port- 
able food  that  will  keep  well  for  a  long  time,  especially  when  pro- 
tected from  drying  by  a  coating  of  tinfoil  or  otherwise.  These  cakes 
contain  condensed  nutriment  which  makes  them  very  serviceable 
upon  expeditions  where  provisions  can  only  be  carried  in  limited 
quantity.  Condensed  milk  may  be  carried  to  drink  with  the  choco- 
late. The  fact  that  its  flavour  is  so  universally  liked  is  an  additional 
advantage. 

The  chocolate  cakes  are  sometimes  prepared  with  meat  extract, 
or  when  dissolved  and  drunk,  meat  powder  or  raw  meat  may  be 
added  to  them  for  phthisical  patients  or  other  invalids  who  require 
concentrated  food. 

Chocolate,  when  not  too  rich  in  fat,  is  a  very  wholesome  food  for 
growing  children,  and  is  better  for  them  than  the  more  stimulating 
beverages  tea  and  coffee.  Its  agreeable  flavour  causes  it  to  be  ex- 
tensively used  as  an  ingredient  of  starchy  foods  and  confections,  and 
also  to  disguise  the  taste  of  disagreeable  or  bitter  medicines,  such  as 


STIMULANTS   AND   BEVERAGES. 


205 


quinine.  Many  articles  of  invalid  diet,  such  as  cornstarch,  farina, 
gelatin,  etc.,  may  be  made  palatable  by  the  addition  of  chocolate, 
while  their  nutritive  qualities  are  enhanced. 

Kola. 

Composition. — The  kola  nut  is  the  fruit  of  a  tall  tree  of  the  or- 
der Sterculiace(£,  growing  in  the  island  of  Jamaica,  on  the  west  coast 
of  Africa,  East  India,  and  Ceylon.  It  resembles  both  coffee  and 
chocolate  in  some  of  its  properties,  and  its  uses  are  practically  the 
same.  It  contains  caffeine,  or  theine  and  theobromine,  besides  a  lit- 
tle fat,  glucose,  dextrin  and  starch,  cellulose,  albumins,  tannin,  mu- 
cilaginous material,  a  diastatic  and  a  milk-digesting  ferment,  and 
other  substances. 

Uses. — Kola  is  believed  to  exercise  a  restraining  influence  upon 
tissue  waste.  It  is  also  mildly  stimulating  to  the  heart  and  nervous 
system,  and  is  diuretic  as  well  as  somewhat  tonic  in  its  action  on  the 
stomach.  It  is  said  to  increase  the  capacity  for  endurance  of  mus- 
cular work. 

Its  efficacy  has  been  repeatedly  tested  by  European  army  sur- 
geons— especially  in  France  and  Switzerland — for  troops  on  the 
march,  and  has  been  shown  to  lessen  fatigue  and  diminish  the  craving 
for  both  food  and  drink. 

Kola  made  into  an  infusion  like  coffee,  but  only  one  third  or  one 
half  the  strength  of  the  latter,  forms  a  smooth,  rich,  dark-brown  fluid 
without  sediment  or  oily  scum.  It  is  drunk,  like  coffee  or  chocolate, 
with  milk  and  sugar,  and  has  a  not  unpleasant  taste.  It  is  said  to  be 
w-ell  borne  by  delicate  stomachs,  and  may  be  prescribed  in  fevers. 
In  large  doses  it  may  cause  insomnia.  As  a  substitute  for  food  on 
forced  marches  or  in  mountain  climbing  it  is  said  by  those  who 
have  tried  it  to  sustain  strength  for  as  long  as  forty  hours,  and  to 
serve  better  than  tea  or  coffee. 

Alcohol. 

Alcohol  is  a  substance  produced  by  a  process  developed  in  cer- 
tain sugar-yielding  substances  (such  as  grains,  molasses,  sugar  cane, 
etc.)  by  the  action  of  an  organised  ferment,  the  yeast  fungus  Saccha- 
romyces  cerevisice.  The  chemical  changes  involved  are  complex,  but 
the  chief  products  are  ethyl  alcohol  and  carbon-dioxide  gas.  A  little 
glycerin,  succinic  acid,  and  other  bodies  may  be  formed.  The  fungus 
is  always  floating  in  the  air,  so  that  when  saccharine  fluids  are  ex- 
posed to  it  the  fermentation  proceeds  of  itself.  Two  parts  of  sugar 
yield  approximately  one  of  alcohol. 

Alcoholic  drinks  may  be  economically  distilled  from  a  great  vari- 
ety of  cereals,  vegetables,  and  fruits  which  contain  sugar,  or  sub- 
stances which  can  be  artificially  converted  into  it.    There  are  no  civil- 


2q6  stimulants,  beverages,  condiments. 

ised  races,  and  but  few  uncivilised  or  semicivilised  people,  with  the 
exception  of  the  northern  Eskimos  and  a  few  other  tribes  mentioned 
below,  who  do  not  practise  the  distillation  of  alcohol  in  some  form 
or  other  from  the  materials  most  available.  For  example,  the  spirit 
fermented  from  the  potato  is  drunk  in  Lombardy,  and  that  from- 
rice  in  Japan,  and  the  Fiji  Islanders  use  a  drink,  "  kava,"  made 
by  fermenting  with  their  own  saliva  the  I'lper  methysticum.  Even 
the  stems  of  plants  are  used,  as  in  the  case  of  alcoholic  beverages 
made  from  the  sugar  cane  and  the  palm.  The  expressed  juices  of 
many  fruits  besides  the  grape  and  apple  can  be  easily  fermented  into 
intoxicating  drinks,  and  when  the  alcoholic  fluid  obtained  lacks  fla- 
vour it  is  often  re-enforced  by  some  organic  extract. 

General  Discussion  of  the  Value  of  Alcohol. — The  question 
whether  alcohol  is,  properly  speaking,  a  food,  or  is  only  to  be 
regarded  as  a  beverage  and  stimulant  without  power  of  nutrition, 
has  given  rise  to  much  warm  discussion,  and  it  invariably  plays  an 
important  role  among  the  advocates  of  teetotalism.  A  full  presen- 
tation of  the  alcohol  question  would  be  foreign  to  the  limits  of  the 
present  work,  but  the  following"  general  propositions  comprise  the 
belief  of  many  authorities  who  have  devoted  careful  research  to 
this  exceedingly  important  topic: 

1.  The  use  of  alcohol  in  any  shape  is  wholly  unnecessary  for  the 
use  of  the  human  organism  in  health.  It  does  not  exist  as  a  natu- 
ral product. 

The  very  lowest  types  of  man — Australian  and  many  Polynesian 
savages — know  nothing  of  it,  and  drink  only  water  and  fresh  fruit 
juice,  such  as  that  of  the  cocoanut,  although  they  speedily  acquire 
a  fondness  for  alcohol  when  it  is  given  them. 

2.  A  large  number  of  persons  are  undoubtedly  better  without 
alcohol  and  may  prolong  their  lives  by  total  abstinence. 

3.  The  lifelong  use  of  alcohol  in  moderation  as  an  occasional 
beverage  with  meals  does  not  necessarily  shorten  the  duration  of 
life  or  induce  disease  in  some  persons,  while  in  others  it  undoubted- 
ly produces  gradual  and  permanent  changes,  chiefly  of  a  cirrhotic 
character,  in  the  blood  vessels  and  in  viscera,  such  as  the  liver  and 
kidneys.  These  alterations,  which  may  be  slow  and  subtile  in  char- 
acter, may  not  in  themselves  materially  impair  the  health  or  cause 
an  ultimately  fatal  result,  but  they  tend  to  weaken  vital  organs 
and  produce  a  condition  of  premature  senility,  so  that  if  the  patient 
be  overtaken  by  any  severe  disease — as,  for  example,  by  an  acute  in- 
fection, like  pneumonia,  or  a  chronic  one,  like  pulmonary  tuberculosis 
— the  resistance  of  the  body  to  the  force  of  the  disease  is  materially 
impaired  and  the  danger  to  the  patient  is  seriously  enhanced. 

4.  There  are  many  persons  whose  constitutional  inheritance  is 
such  that  they  should  be  particularly  warned  against  the  use  of 

A 


STIMULANTS   AND   BEVERAGES. 


207 


alcohol,  and  in  some  such  cases,  as,  for  example,  among  those  who 
are  subjects  of  well-marked  gouty  diathesis,  it  is  better  that  the  use 
of  alcohol  should  be  imperatively  forbidden. 

5.  The  abuse  of  alcoholic  stimulation  is  invariably  injurious, 
although  the  extent  to  which  evil  influences  become  manifest  de- 
pends upon  the  constitution  of  the  individual,  in  connection  with 
the  two  factors  of  heredity  and  environment. 

6.  There  are  a  number  of  diseases  in  which  the  temporary  use 
of  alcohol  is  of  positive  service,  and  there  are  a  number  of  cases 
in  which  it  becomes  a  necessity  in  order  to  prolong  life. 

7.  In  many  cases  of  malnutrition  and  malassimilation  of  food, 
alcohol  is  itself  a  food,  and  its  consumption  under  proper  direction 
results  in  an  increase  of  body  weight  and  strength  and  improve- 
ment of  functional  activity.  These  results  are  accomplished  in  part 
through  the  action  of  the  alcohol  as  a  definite  food,  and  in  part  through 
its  remarkable  effect  in  force  production.  The  latter  is  due  to  its 
own  direct  combustion,  by  which  in  chronic  diseases  and  in  critical 
acute  and  exhausting  affections  it  spares  that  of  the  tissues  of  the 
body. 

Although  alcohol  is  such  a  strong  force  producer  and  heat 
generator,  its  effect  in  this  direction  is  very  soon  counterbalanced 
by  its  stronger  influence  in  lowering  the  general  tone  of  the  nerv- 
ous system  and  in  producing  positive  degeneration  in  the  tissues. 
In  the  condition  of  health  more  food  is  usually  eaten  and  more 
force  is  developed  than  is  actually  necessary  for  the  body,  and  there 
is  constantly  a  reserve  supply  of  energy  on  hand  which  may  be  util- 
ised for  any  extraordinary  exertion,  and  hence  the  constant  use  of 
alcohol  as  a  food  or  stimulant  in  health  is  both  unnecessary  and 
unadvisable.  When  alcohol  is  consumed  in  health  in  addition  to  a 
normal  or  excessive  quantity  of  solid  food  by  its  more  ready  com- 
bustion it  prevents  the  complete  oxidation  of  the  latter  and  favours 
the  accumulation  of  suboxidised  waste  products,  which  are  always 
harmful  in  the  system.  Excesses  in  eating  are  thus  doubly  aggra- 
vated by  the  effects  of  alcohol.  It  is  the  almost  universal  testi- 
mony of  army  surgeons  and  the  experience  of  those  who,  like 
Greely,  Stanley,  and  others,  have  led  long  and  perilous  exploring 
expeditions,  involving  great  fatigue  and  unusual  endurance,  that 
muscular  overwork  and  climatic  hardships  are  much  better  endured 
if  alcohol  is  entirely  abstained  from. 

It  has  always  been  found  in  armies  that  when  good  food  was  at 
hand  the  issue  of  alcohol  with  the  regular  ration  produced  an 
increased  percentage  of  sick  days  and  of  incapacity  for  work. 
Colonel  Alfred  A.  Woodhull,  Surgeon,  U.  S.  Army,  writes  me  in  re- 
gard to  this  matter  :  "  I  do  not  think  that  any  of  our  medical  offi- 
cers would  seriously  advocate  the  issue  of  alcohol  as  a  measure  of 
16 


2o8  STIMULANTS.   BEVERAGES,   CONDIMENTS. 

health,  but  I  believe  that  its  habitual  use  during  the  rebellion  was 
prohibited  for  reasons  of  discipline,  while  it  still  might  have  been 
occasionally  issued  as  if  for  health.  On  the  rare  occasions  when  it 
might  serve  a  good  purpose  as  a  temporary  stimulant  after  a  long 
and  wet  march,  the  waggons  would  be  in  the  rear  owing  to  the  same' 
conditions  that  fatigued  the  men." 

While  all  this  applies  to  prolonged  effort  of  any  kind  and  to 
conditions  where  other  food  can  be  obtained  and  assimilated,  it 
does  not  detract  from  the  fact  that  alcohol  is  a  most  helpful  food 
and  stimulant  in  emergencies  when  other  food  cannot  be  had  or 
when  the  body  is  temporarily  endangered  from  acute  disease  and 
the  higher  rate  of  combustion  in  fever,  or  from  failure  to  assimilate 
other  nourishment. 

Captain  Woodruff,  Assistant  Surgeon,  tI^_S:^Army,  says  :  "  Spirits 
can  never  be  used  in  the  army  as  a  regular  issue ;  the  practice  is 
thoroughly  vicious,  and  was  virtually  abandoned  sixty  years  ago. 
On  extraordinary  occasions  of  great  fatigue  they  are  allowable  in 
moderation.  Under  such  temporary  stimulation  the  men  will  brace 
up  and  perform  the  necessary  work  of  making  earthworks,  etc., 
when  without  it  they  would  be  too  exhausted  to  do  anything.  With- 
out stimulation  a  man  is  not  worth  much  after  he  has  made  a  forced 
march  of  forty  miles." 

The  problem  whether  the  world  as  a  whole  is  better  or  worse  for 
the  existence  of  alcohol  aside  from  all  ethical  questions,  and  viewed 
merely  from  the  scientific  standpoint  of  the  influence  of  alcohol 
upon  mortality,  is  difficult  of  solution,  for  to  offset  the  numerous 
cases  of  fatal  alcoholism  and  the  still  larger  number  of  cases  of  dis- 
eases which  would  not  presumably  be  fatal  without  the  existing 
condition  of  chronic  alcoholic  poisoning  of  the  system,  are  very 
many  cases  among  both  infants  and  adults  in  which  life  is  un- 
doubtedly saved  by  the  prompt  resort  to  this  food  and  stimulant 
and  its  energetic  use.  So  long  as  man  is  exposed  to  hardships  and 
conditions  arising  from  improper  and  deficient  food  supply  as  well 
as  to  the  numerous  infectious  diseases  to  which  he  is  heir,  alcohol 
must  still  be  regarded  rather  as  a  blessing  than  a  curse,  for  there  is 
no  form  of  stimulant  and  food  combined  or  stimulant  alone  which, 
taken  all  in  all,  can  be  so  completely  relied  upon  in  cases  of  emer- 
gency. Alcohol  when  taken  alone  will  prolong  life  beyond  the 
period  at  which  it  terminates  from  starvation. 

Physiological  Action. — The  physiological  effects  of  alcohol 
may  be  considered  under  several  headings : 

I,  Action  as  a  Food.  II.  Action  as  a  Stimulant  to  the  Nerves 
and  Circulation.  III.  Action  upon  the  Muscular  System.  IV,  Ac- 
tion upon  the  Body  Temperature.  V.  Action  as  a  Diuretic.  VI. 
Action  upon  Mucous  Membranes.     VII.  Action  upon  Gastric  Diges- 


STIMULANTS   AND   BEVERAGES. 


209 


tion.     VIII.  Alcohol  Absorption — Hypodermic  Use.     IX.    Elimina- 
tion of  Alcohol.     X.  Alcohol  Poisoning.     XI.  Alcohol  and  Climate. 

I.  Action  as  a  Food. — As  a  food,  alcohol  adds  to  the  nutrition 
of  the  body  by  its  prompt  absorption,  requiring  no  preliminary  prep- 
aration by  the  digestive  organs,  which  are  therefore  not  taxed  in 
any  degree,  and  it  is  immediately  conveyed  in  the  general  circula- 
tion to  the  liver  and  other  parts'  of  the  system.  The  chemical 
changes  involved  in  the  assimilation  of  this  form  of  hydrocarbon  are 
but  ill  understood.  Alcohol,  even  when  digested  in  very  large  quan- 
tity, does  not  reappear  to  any  extent  unaltered  in  the  urine,  and, 
if  not  taken  in  excess,  it  is  not  exhaled  from  the  breath,  demonstrat- 
ing that  its  combustion  is  complete.  This  combustion  results  in  the 
formation  of  water  and  carbon  dioxide.  The  fact  that  the  body 
weight  may  increase  under  its  use,  and  that  the  storage  of  fat  in  the 
tissues  may  be  also  increased  even  to  an  abnormal  degree,  does  not 
absolutely  prove  that  the  alcohol  itself  has  entered  into  their  struc- 
ture. Its  action  may  be  exerted  through  modification  of  oxidation 
processes  or  by  preventing  the  burning  up  of  other  food  materials, 
which  are  thereby  enabled  to  be  themselves  added  to  the  protoplas- 
mic elements  of  the  body;  yet  there  is  reason  to  believe  that  while 
the  latter  is  the  chief  effect  of  alcohol  as  a  food,  it  also  may  be 
directly  stored  in  the  body  in  the  form  of  some  other  product. 

In  referring  to  the  influence  of  alcohol  upon  metabolism  Bauer 
says :  "  The  increase  of  albumin  suffers  thereby  no  appreciable 
change;  that  of  fat,  on  the  other  hand,  is  reduced  by  small  quantities 
of  alcohol,  while  by  very  large  doses  it  is  increased  at  any  rate  in 
animals.  Alcohol  also,  in  consequence  of  its  fat-sparing  action, 
behaves  in  the  character  of  a  food."  The  sugar  which  is  contained' 
in  considerable  quantity  in  sweet  wines,  liqueurs,  etc.,  is  an  addi- 
tional source  of  nourishment  or  of  fat  production.  It  is  a  matter  of 
common  observation  that  many  heavy  drinkers  are  stout.  They 
usually  indulge  more  freely  in  unsweetened  liquors  or  malt  liquors 
than  in  wines,  however.  Heavy  drinkers  are  often  heavy  eaters, 
and  may  be  as  unable  to  control  their  appetite  for  food  as  for  drink. 
This  of  course  does  not  apply  to  cases  of  alcoholic  gastritis,  in  which, 
temporarily  at  least,  all  desire  for  food  may  be  in  abeyance.  In  a 
general  way,  alcohol  is  believed  to  lessen  tissue  waste. 

The  consumption  of  alcohol  is  said  to  increase  the  quantity  of 
oxygen  inspired  and  lessen  the  carbonic  acid  exhaled. 

II.  Action  as  a  Stimulant  to  the  Nerves  and  Circulation.— 
As  a  stimulant,  alcohol  acts  primarily  upon  the  nervous  system  and 
the  circulation,  although  it  increases  the  functional  activity  of  many 
organs  in  the  body,  and  gland  secretion  may  be  promoted  by  its  use. 
The  influence  of  alcohol  upon  the  nervous  system  in  moderate  doses 
is  to  quicken  the  transmission  and  enhance  the  effect  of  nerve  cur- 


2;iO  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

rents,  accelerating  slightly  the  heart  action  and,  to  a  lesser  degree, 
the  respiration,  while  the  mental  processes  are  stimulated  in  part  by 
its  direct  influence  upon  the  cerebrum,  and  in  part  also  by  the  greater 
rapidity  of  the  circulation. 

If  alcohol  is  given  in  large  doses  at  frequent  intervals,  it  may 
overstimulate  the  heart,  which  subsequently  becomes  exhausted  as 
the  result  of  the  stimulation.  This  is  sometimes  true  of  the  senile 
heart. 

III.  Action  upon  the  Muscular  System. — Alcohol  used 
within  physiological  limits  tends  to  remove  muscular  fatigue  and 
to  increase  the  force  of  muscular  action. 

In  the  training  of  athletes  for  contests  in  rowing,  sparring,  and 
other  sports,  alcohol  is  usually  absolutely  forbidden,  and  it  is  believed 
that  the  breakdown  in  health  which  by  many  athletes  is  ascribed  to 
overwork  is  not  infrequently  due  to  violations  in  regard  to  the  sim- 
ple physiological  laws  of  the  effect  of  alcohol  which  the  accompany- 
ing features  of  a  "sporting"  life  tempt  them  to  infringe.  The  ques- 
tion is  well  stated  by  Ringer,  who  says  :  "  There  can  be  no  doubt  that 
healthy  persons  capable  of  the  fullest  amount  of  mental  and  physical 
exercise  without  the  stimulation  of  alcohol  not  only  do  not  require 
it,  but  are  far  better  without  it."  But,  as  he  remarks,  the  statement 
applies  to  the  continued  use  of  strong  alcoholic  spirits,  and  not  to 
beers  and  light  wines  which,  in  addition  to  the  alcohol,  contain 
other  ingredients  which  may  be  serviceable  as  food.  In  the  latter 
form  of  beverages  the  quantity  of  alcohol  is  comparatively  small, 
and  the  constant  use  of  them  is  found,  by  the  practical  experience 
of  many  persons  whose  occupations  preclude  them  from  abundant 
exercise  in  the  open  air  in  the  country,  to  improve  their  digestion 
and  enable  them  to  sustain  various  functions  of  the  body  which 
would  otherwise  be  impaired  by  their  mode  of  life.  This  is  espe- 
cially true  of  elderly  people  and  those  who  suffer  from  insomnia  and 
retardation  of  gastric  digestion 

IV.  Action  upon  the  Body  Temperature. — The  physiological 
effect  of  alcohol  upon  the  body  temperature  may  also  be  regarded 
as  proceeding  primarily  from  its  stimulating  influence,  acting  through 
the  vasomotor  nerves.  In  moderate  doses,  alcohol,  by  quickening 
the  rapidity  of  the  circulation  and  by  dilating  the  peripheral  blood 
vessels,  enables  more  blood  to  reach  the  surface  of  the  body  and 
to  pass  through  the  superficial  capillaries  in  a  given  time,  and  hence 
there  is  a  tendency  to  lower  the  body  temperature.  On  the  other 
hand,  the  combustion  of  the  alcohol  itself  within  the  body  results 
in  the  production  of  a  large  number  of  heat  units.  The  total  bal- 
ance of  these  processes  is  usually  on  the  side  of  an  absolute  reduc- 
tion of  the  temperature.  It  is  in  part  for  this  reason  that  alcohol  is 
of  benefit  in  fevers. 


STIMULANTS   AND   BEVERAGES.  211 

As  a  result  of  an  elaborate  series  of  experiments  made  by 
Reichert  to  determine  the  action  of  alcohol-  on  animal  heat  func- 
tions (Therap.  Gaz.,  Feb.  15,  1890),  he  concludes  "that  alcohol 
does  not  affect  the  total  quantity  of  heat  produced ;  that  more  heat 
is  dissipated  than  produced ;  that  the  fall  of  temperature  is  due  to 
the  excess  of  dissipation,  and  is  in  direct  proportion  ;  and  that  in 
all  likelihood  alcohol,  by  undergoing  oxidation,  yields  energy  in  the 
form  of  heat,  thus  conserving  the  tissues  and  acting  as  a  food." 

V.  Action  as  a  Diuretic. — Alcohol  in  some  persons,  although 
not  in  all,  is  a  very  strong  diuretic,  and  its  effect  depends  largely 
upon  the  variety  of  the  beverage  used.  For  some  persons  gin  has 
a  much  more  decided  diuretic  action  than  other  strong  liquors,  such 
as  rum  or  brandy,  and  in  many  beer  possesses  a  diuretic  action 
which  indicates  a  special  stimulating  effect  upon  the  total  quantity 
of  urine  excreted  beyond  that  which  would  be  produced  by  a  similar 
bulk  of  water,  but  the  total  urea  eliminated  may  be  diminished. 
As  a  general  rule,  alcohol  which  is  moderately  diluted,  and  which  is 
taken  upon  an  empty  stomach,  is  much  more  promptly  absorbed  and 
possesses  a  stronger  diuretic  action  than  when  taken  with  food  or 
when  given  in  a  concentrated  form. 

VI.  Action  on  Mucous  Membranes. — Strong  alcohol  is  astrin- 
gent to  mucous  surfaces,  and  it  is  sometimes  used  diluted  with  equal 
parts  of  water  as  a  gargle  for  sore  throat.  Claret,  which  also  con- 
tains tannin,  may  be  employed  in  this  way. 

If  taken  in  too  large  quantity  or  too  strong,  the  astringent  effect 
upon  the  stomach  is  highly  irritating,  causing  local  congestion,  and 
even  inflammation  upon  the  mucous  coat,  which  becomes  covered 
with  tenacious  mucus.  The  tongue  soon  becomes  coated,  and  the 
appetite  is  destroyed  as  well  as  the  secreting  power  of  the  gastric 
glands. 

VII.  Action  upon  Gastric  Digestion. — Taken  with  food  in 
the  stomach,  alcohol  in  small  quantities,  not  exceeding  the  equiva- 
lent of  half  an  ounce  of  the  pure  substance,  given  in  the  form  of 
any  alcoholic  beverage,  does  not  materially  affect  the  action  of  the 
gastric  juice.  In  larger  quantities,  or  if  the  gastric  juice  itself  is 
feeble,  alcohol  precipitates  pepsin,  coagulates  the  albuminous  ma- 
terials of  the  food,  and  greatly  retards  if  it  does  not  altogether  de- 
stroy gastric  digestion.  On  the  other  hand,  while  not  interfering 
with  the  action  of  the  gastric  juice,  alcohol  may  stimulate  its  secre- 
tion so  that,  as  Moleschott  says,  "  a  glass  or  two  of  good  old  wine 
increases  the  quantity  of  gastric  juice,  which  performs  mainly  the 
digestion  of  albuminous  foods." 

Some  interesting  experiments  are  reported  by  Roberts  (Lectures 
on  Dietetics  and  Dyspepsia)  upon  the  effect  of  malt  liquors  on  gas- 
tric digestion.     They  were  conducted  as  follows  :    By  adding  to- 


212 


STIMULANTS,   BEVERAGES,   CONDIMENTS. 


gether  2  grammes  of  dried  beef-fibre,  0.15  c.  c.  of  hydrochloric  acid, 
I  c.  0.  of  glycerin  extract  of  pepsin,  and  varying  quantities  of  malt 
liquors,  with  water  up  to  100  c.  c. 


Proportion  of  Malt  Liquors  coNTAtNKB, 
IN  THE  Digesting  Mixture. 


10  per  cent 
20    "       " 
40    "       " 
60    "       " 


TIME    IN    WHICH   DIGESTION   WAS  COMPLETED. 
(normal,    100   MINUTES.) 


Burton  ale. 


\ie,  minutes. 
140        " 
200        " 
Embarrassed. 


Light  English 
table  beer. 


100  mmutes. 
115 

140        " 
180        " 


Lager  beer. 


100  minutes. 

115 

140        " 

180 


In  considering  the  relation  of  alcohol  to  other  foods,  the  fact 
should  be  emphasised  that  monotony  of  diet  with  poor  cooking  of 
coarse,  tasteless  food,  especially  when  combined  with  overwork,  may 
be  a  potent  factor  in  establishing  a  liking  for  liquors  among  the 
poor.  In  the  United  States,  among  the  poorer  classes  the  art  of 
varying  the  diet  and  of  serving  food  in  an  agreeable  and  properly 
seasoned  manner  is  but  imperfectly  understood,  and  the  statement  is 
confidently  made  by  Williams,  who  has  given  some  years  of  personal 
attention  to  the  matter,  that  "  the  raw  material  of  the  dietary  of  the 
French  and  Italians  is  more  inferior  than  that  of  the  English,  but  a 
far  better  result  is  obtained  by  better  cookery,  and  the  same  un- 
favourable comparison  can  undoubtedly  be  made  with  the  poorer 
classes  in  America."  The  Italians  have  the  art  of  making  compara- 
tively tasteless  food,  such  as  macaroni,  into  very  savoury  and  nutri- 
tious dishes. 

Osier  expresses  the  opinion  that  more  ill  arises  from  abuses  of 
eating  than  of  drinking,  especially  in  America. 

VIII.  Alcohol  Absorption. — Alcohol  is  highly  diffusible,  and 
is  promptly  absorbed  from  mucous  surfaces  as  well  as  from  subcu- 
taneous tissue. 

Its  effect  is  always  more  immediate  when  taken  into  an  empty 
stomach.  It  is  then  rapidly  absorbed,  and  its  influence  is  exerted 
suddenly.  When  there  is  food  in  the  stomach,  some  of  the  alcohol 
is  temporarily  taken  up  by  it  like  water  by  a  sponge,  its  absorption 
is  delayed,  and,  since  its  elimination  is  quite  rapid,  the  system  is  less 
apt  to  become  overcharged  with  it. 

Alcohol  is  well  absorbed  from  the  rectum,  and  to  patients  who 
for  any  reason  are  unable  to  retain  it  in  the  stomach  it  may  be 
given  in  this  manner.  For  this  purpose  it  is  best  to  use  spirits 
diluted  with  from  one  to  four  parts  of  water,  and  an  ounce  of 
whisky  or  brandy  should  be  given  for  a  dose. 

Hypodermic  Use. — Very  little  alcohol  can  be  made  to  pass  into  the 
body  by  rubbing  it  upon  the  skin,  although  it  is  a  diffusible  sub- 
stance, but  it  is  very  promptly  absorbed  when  injected  hypodermic-. 


STIMULANTS   AND   BEVERAGES. 


213 


ally,  and  where  its  immediate  stimulating  effect  is  required  it  can 
be  thus  sooner  obtained.  Owing  to  the  local  irritant  action  of 
alcohol,  not  over  half  a  drachm  or  a  drachm  should  be  placed  be- 
neath the  skin  at  any  one  point,  for  it  is  often  quite  painful.  The 
surface  should  be  rubbed  to  promote  its  absorption.  In  emergency 
two  or  three  ounces  may  be  quickly  given  in  this  way  in  divided 
doses. 

IX.  Elimination. — It  is  unfortunate  that  the  experiments  made 
to  determine  the  influence  of  alcohol  upon  the  nature  and  quantity 
of  the  various  excretions  of  the  body — urea,  uric  acid,  carbonic  acid, 
etc. — have  not  given  uniform  results.  The  questions  of  what  inter- 
mediate products  may  be  formed  by  the  splitting  up  of  alcohol  in  the 
blood  or  tissues,  of  the  influence  of  the  combustion  of  alcohol,  and 
of  the  combustion  of  the  tissues  themselves,  involve  great  difficulties 
in  the  way  of  chemical  analysis,  and  the  liabilities  to  error  are  con- 
siderable. It  may  be  regarded  as  proved,  however,  that  when  taken 
in  moderation  alcohol  is  completely  consumed  within  the  body,  or  so 
completely  that  a  mere  trace  escapes  in  the  urine  and  perspiration, 
and  a  little  more  in  the  exhaled  air.  If  the  dosage  of  alcohol  is  very 
much  increased,  however,  its  elimination,  unaltered,  becomes  propor- 
tionately active,  although  it  is  still  consumed  in  large  amount  in  the 
body. 

Alcohol  is  believed  to  prevent  the  elimination  of  tissue  waste  under 
some  conditions,  and,  in  spite  of  the  fact  that  it  acts  as  a  diuretic,  it 
may  lessen  the  excretion  of  urea  and  uric  acid. 

X.  Alcohol  Poisoning. — This  topic  will  be  more  conveniently 
discussed  with  the  treatment  under  the  heading  Alcoholism. 

XI.  Alcohol  and  Climate. — It  is  an  established  fact  that  cli- 
matic conditions  exercise  an  important  influence  upon  the  degree  to 
which  alcohol  influences  the  system.  Many  persons  find  that  they 
can  drink  more  spirits  and  wine  during  a  prolonged  residence  in  a 
climate  like  that  of  England  without  apparent  ill  effect  than  they  can 
in  the  more  stimulating  and  bracing  climate  with  greater  extremes  of 
temperature  which  exists  in  many  parts  of  the  United  States.  If  men 
are  to  be  exposed  to  cold  and  hardship  for  a  considerable  period  of 
time  it  is  highly  unwise  for  them  to  indulge  freely  in  alcoholic  drinks 
on  account  of  the  rapid  fall  in  the  body  temperature,  which  is  pro- 
moted by  the  external  cold  when  alcohol  relaxes  the  capillaries.  In 
illustration  of  this  principle,  a  story  is  often  told  of  a  party  of  engi- 
neers who  were  lost  during  the  winter  in  the  Rocky  Mountains,  where, 
after  prolonged  exposure  to  cold  and  hardship,  they  were  one  night 
obliged  to  sleep  without  shelter  with  the  thermometer  below  zero. 
They  had  whisky  with  them  and  but  little  food ;  some  of  the  party 
drank  heavily,  others  drank  in  moderation,  and  a  few  of  the  wisest 
took  no  alcohol  at  all.     lii  the  morning  the  latter  awoke,  cold  but 


2,14  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

refreshed  by  the  night's  rest,  while  others  who  drank  in  moderation 
were  very  much  more  uncomfortable  and  had  suffered  far  more  from 
the  exposure,  and  one  or  two  of  those  who  had  drunk  freely  were 
frozen  to  death. 

In  the  arctic  expeditions  of  Greely,  De  Long,  and  others,  although 
pure  alcohol  was  carried  for  cooking  purposes,  very  stringent  regula- 
tions had  to  be  enforced  to  prevent  the  men  from  drinking  alcoholic 
beverages,  which  were  only  kept  for  emergencies  and  sickness.  It  is 
perhaps  one  of  the  wisest  provisions  of  Nature  that  the  northern 
Eskimos  are  ignorant  of  such  drinks,  having  nothing  in  their  range 
of  food  stuffs  which  they  can  ferment  so  as  to  produce  them.  On 
the  other  hand,  the  natives  of  warmer  and  tropical  climates  are  in 
the  habit  of  distilling  many  varieties  of  alcoholic  drink  from  the  fer- 
mentation of  vegetable  food. 

CLINICAL    USES   OF   ALCOHOL. 

1.  Use  as  a  Tonic. — Very  moderate  doses  of  alcohol  increase 
the  flow  of  gastric  juice,  and  for  this  reason  it  may  be  employed  with 
advantage  in  eases  such  as  the  following :  i.  By  those  whose  nervous 
system  is  readily  overtaxed  and  who  when  fatigued  or  worried  lose 
all  appetite.  2.  By  persons  of  sedentary  habits  who  have  greatly 
enfeebled  digestions.  3.  In  protracted  convalescence  from  severe 
forms  of  acute  diseases.  For  any  of  these  patients  a  mild  cocktail, 
or  a  little  whisky  and  water,  or  a  glass  of  simple  bitters  may  be 
ordered  to  be  taken  directly  before  meals  in  order  to  improve  the 
"tone"  of  the  stomach.  In  all  cases  care  should  be  exercised,  espe- 
cially among  persons  who  may  possibly  inherit  the  alcoholic  habit, 
that  the  beverage  be  not  prescribed  too  often,  for  sometimes  cases  of 
chronic  alcoholism  originate  among  persons  who  begin  by  resorting 
to  this  food  and  stimulant  ta  tide  them  over  emergencies  such  as  the 
above,  and  who  find  when  the  emergency  is  passed  that  they  are 
unable  to  relinquish  the  acquired  fondness  for  the  drink. 

2.  Use  as  a  Vascular  and  Cardiac  Stimulant. — If  there  is 
general  arterial  relaxation  from  debilitating  disease,  the  use  of  alco- 
hol in  proper  quantities  contracts  the  vessels  somewhat  and  improves 
the  firmness  and  quality  of  the  pulse  to  a  remarkable  degree.  Alco- 
hol undoubtedly  can  be  given  the  first  place  among  the  cardiac  stimu- 
lants, for  its  combined  action  in  strengthening  the  heart  and  regulat- 
ing the  calibre  of  the  blood  vessels  is  most  useful.  For  this  purpose 
it  is  best  to  use  strong  liquors,  such  as  brandy  or  whisky,  which  vary 
but  little  in  composition,  and  which  may  be  diluted  according  to  need. 
In  all  cases  of  sudden  heart  failure  occasioned  by  shock,  violent  haem- 
orrhages, either  internal  or  external,  fainting,  etc.,  it  is  best  to  give 
alcohol  in  the  form  of  diluted  spirits. 

It  is  an  interesting  fact  that  the  mere  mechanical  action  of  deglu- 


STIMULANTS   AND   BEVERAGES. 


215 


tition  stimulates  the  heart  action  and  increases  the  rate  of  pulse  beats 
by  fifteen  or  twenty  in  the  second.  Stimulants  sipped  slowly  by  re- 
peated acts  of  swallowing  for  this  reason  alone  may  have  a  greater 
effect  than  the  same  quantity  of  fluid  drunk  all  at  once.  In  extreme 
emergencies,  whether  the  patient  is  able  to  swallow  or  not — as,  for 
example,  in  shock  from  prolonged  anaesthesia,  or  from  the  use  of 
anaesthetics  which  are  not  well  tolerated,  and  in  an  urgent  case  when 
the  alcohol  is  given  by  hypodermic  injection — it  may  be  used  undi- 
luted. Its  influence  in  these  conditions  is  almost  immediate,  and  the 
stimulation  of  the  pulse  may  be  appreciated  in  two  or  three  minutes. 
A  little  more  time  is  required  for  the  full  effect  if  the  stimulant  is 
given  by  the  stomach.  The  benefit  of  alcohol  in  these  cases  is  further 
shown  by  the  tongue  and  skin  becoming  more  moist,  by  the  slowing 
of  the  pulse,  and  by  the  breathing  becoming  more  tranquil.  Since 
alcohol  regulates  arterial  tone  and  brings  the  pulse  to  a  nearer  nor- 
mal standard,  the  volume  of  the  pulse  is  not  so  important  a  consider- 
ation as  is  its  compressibility  as  a  factor  in  estimating  the  value  of 
alcohol  in  a  given  case.  The  very  soft  pulse  of  considerable  volume 
may  diminish  in  volume  under  the  use  of  alcohol,  but  it  becomes 
firmer  and  of  better  character,  showing  an  improvement  in  the 
arterial  tone.  The  rules  for  observing  the  effect  of  alcohol  may  be 
definitely  applied  in  almost  every  case,  and  the  dosage  can  be  regu- 
lated accordingly.  In  acute  diseases,  such  as  pneumonia,  in  which 
the  emergency  of  cardiac  failure  or  great  prostration  may  be  fairly 
anticipated,  it  is  often  better  to  withhold  alcohol  until  there  are  defi- 
nite indications  for  its  use  than  it  is  to  prescribe  it  in  a  routine  man- 
ner at  the  commencement  of  the  disease ;  its  effect  when  actually 
needed  is  enhanced  if  it  has  not  been  already  given  for  too  long  a 
time.  For  persons  with  feeble  constitutions,  however,  and  for  aged 
people  it  may  be  necessary  to  commence  the  use  of  alcohol  at  an 
earlier  period.  In  urgent  cases  full  doses,  such  as  an  ounce  an  hour, 
may  become  necessary  for  a  few  times,  and  the  quantity  and  inter- 
vals for  its  administration  may  then  be  gradually  reduced.  Usually 
when  the  stimulating  and  supporting  influence  of  alcohol  is  urgently 
needed  it  is  better  to  give  it  in  quite  frequent  doses  and  in  moderate 
quantity  than  in  large  amount  infrequently.  The  stimulation  is  then 
more  uniform  and  constant,  and  the  digestive  organs  are  less  apt  to 
be  deranged. 

3.  Use  in  Nervous  Diseases. — Alcohol  is  of  service  for  many 
forms  of  diseases  of  the  nervous  system.  Neuralgic  pains  are  some- 
times allayed  by  the  use  of  alcoholic  drinks  which  contain  volatile 
ethers,  but  they  should  be  prescribed  with  care.  In  any  neuralgic 
or  nervous  affections,  such  as  hysteria,  which  are  more  or  less 
chronic,  it  is  well  to  observe  that  many  of  the  so-called  elixirs,  nerve 
tonics,  etc.,  which  are  recommended  for  cases  of  this  nature,  and 


2i6  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

especially  for  treatment  of  nervous  prostration,  contain  a  large  per- 
centage of  alcohol,  and  their  constant  and  indiscriminate  use  is  liable 
to  establish  permanent  alcoholism.  In  the  stomach  alcohol  may  act 
as  an  anaesthetic  in  cases  of  irritant  nervous  dyspepsia  (Chambers). 

4.  Use  in  Fevers. — The  whole  question  of  the  employment  of 
alcohol  in  fevers  is  obviously  of  grave  importance. 

The  value  of  alcohol  in  the  treatment  of  fevers  is  now  universally 
recognised,  and  its  beneficial  effect  is  manifested  in  two  ways:  first, 
upon  the  vital  functions  of  the  nervous  system,  circulation,  and  heat 
regulation  ;  and,  secondly,  in  sparing  the  tissues  from  too  rapid  com- 
bustion and  wasting  by  furnishing  fuel  in  their  stead.  In  fever  the  • 
increased  nitrogenous  waste  is  evidenced  by  the  greater  elimination 
of  urea  from  the  kidneys,  while  the  quantity  of  urine  and  perspira- 
tion are  lessened.  The  use  of  alcohol  meets  all  indications  by^X^^ 
lessening  the  production  of  nitrogenous  waste,  by  acting  as  a  diu- 
retic, and  by  regulating  the  peripheral  blood  pressure  and  increasing 
the  perspiration.  To  accomplish  these  results,  usually  six  or  eight 
ounces  in  the  twenty-four  hours,  and  often  much  more,  must  be  given. 

As  a  mere  antipyretic  the  influence  of  alcohol  is  less  striking 
than  that  of  many  special  remedies  which  have  the  power  of  reduc- 
ing the  body  temperature,  but  it  has  the  decided  advantage  over 
most  of  these  remedies  ^that  its  proper  use  is  accompanied  by  stimu- 
lation rather  than  depression  of  the  heart  action. 

It  may  be  regarded  as  a  general  rule  that  when  given  in  large 
quantities  if  the  odour  of  alcohol  is  not  present  in  the  breath  several 
hours  after  it  has  been  ingested,  and  if  the  pulse  is  slowed  and  deli- 
rium is  reduced  under  its  use,  the  amount  taken  is  clearly  being 
oxidised  as  a  food  and  is  doing  good.  On  the  other  hand,  if  the 
odour  persists  in  the  breath  and  the  pulse  is  not  improved,  or  the 
patient  becomes  more  delirious,  it  indicates  that  too  much  alcohol 
is  being  given,  and  the  dosage  should  be  accordingly  reduced. 

The  effect  of  alcohol  in  fevers  is  shown  by  the  fact  that  in 
health,  when  drunk  in  large  quantities,  it  excites  gastric  catarrh 
and  occasions  dyspepsia,  whereas  a  similar  amount  taken  in  the 
height  of  an  acute  fever  may  be  very  beneficial. 

It  must  not  be  inferred  from  the  foregoing  statements  that  alco- 
hol should  be  given  at  once  in  fever,  or  that  it  should  be  given  in 
every  fever.  There  are  many  cases  in  which  it  is  contraindicated. 
Such  are  of  sthenic  type  and  of  short  duration.  There  are  others  in 
which  it  is  a  mistake  to  give  it  too  early,  and  its  use  should  be  post- 
poned until  the  conditions  are  present  of  prostration  and  nervous 
exhaustion.  There  are  still  other  cases  in  which  it  should  be  pre- 
scribed at  once.  Such  are  diphtheria  or  capillary  bronchitis  in 
young  children,  broncho-pneumonia  in  the  aged,  pneumonia  in  feeble 
or  elderly  subjects,  etc.        .    . 


STIMULANTS   AND   BEVERAGES. 


217 


The  general  indications  fotthe  use  of  alcohol  as  a  food  in  con- 
tinued fevers  or  for  an  increase  of  the  quantity  already  being  given 
are  found  in  the  predominance  of  one  or  more  of  the  following  symp- 
toms :  Increased  weakness  or  faintness,  low  muttering  delirium  con- 
tinued even  when  the  patient  is  undisturbed,  tremor  of  the  tongue 
and  hands,  great  dryness  of  the  tongue,  extreme  feebleness  of  the 
voice,  irregularities  in  the  respiration  and  pulse,  enfeebled  or  irregu- 
lar heart  action,  and  absence  of  either  of  the  cardiac  sounds. 

There  is  a  tendency  at  the  present  time  to  abandon  excessive 
dosage  of  alcohol  in  severe  acute  febrile  infectious  diseases,  such 
as  pneumonia  and  typhoid  fever,  in  which  it  was  formerly  given 
at  the  rate  of  an  ounce  an  hour  or  twenty-four  ounces  per  diem, 
for  it  is  found  that  other  stimulants,  such  as  digitalis,  strychnine, 
caffeine,  etc.,  make  it  possible  to  use  less  spirits.  A  full  discussion 
of  this  topic  will  be  found  under  the  heading  Dietetic  Treatment  of 
Fever. 

Young  children  and  even  infants  bear  alcohol  extremely  well, 
and  in  the  emergencies  which  arise  in  severe  cases  of  diphtheria 
or  in  exanthemata  many  lives  may  be  saved  by  its  early  and  ener- 
getic use. 

In  the  treatment  of  convalescence,  when  patients  are  able  to 
digest  and  assimilate  more  and  more  food,  less  alcohol  is  required. 

Proper  Time  for  giving  Alcohol. — Whenever  alcohol  is  pre- 
scribed by  the  physician,  the  time  at  which  it  is  to  be  given  should  be 
explicitly  stated,  and  there  should  be  supervision  over  the  quantity 
used,  depending  upon  the  influence  upon  appetite  and  activity  of  di- 
gestion. When  needed  as  a  tonic,  alcohol  should  be  given  either  im- 
mediately before  or  in  connection  with  meals,  in  order  that  its  effect 
may  be  modified  by  that  of  other  foods.  There  is  less  fear  of  estab- 
lishing a  craving  for  drink  if  this  rule  be  observed.  It  is  the  habit 
of  drinking  between  meals  without  definite  purpose  which  is  partic- 
ularly dangerous. 

In  some  cases  of  neurasthenia,  anaemia,  etc.,  it  may  be  advisable 
to  recommend  a  glass  of  claret  or  sherry  between  the  principal  meals, 
in  the  middle  of  the  morning  or  afternoon,  but  even  then  it  should 
be  taken  with  some  article  of  light  and  easily  digestible  food,  such 
as  a  biscuit  or  sandwich.  The  fact  that  moderate  doses  of  alcohol 
improve  the  functional  activity  of  the  stomach  affords  an  oppor- 
tunity for  the  better  digestion  of  food  given  in  connection  with  alco- 
hol, which  should  not  be  lost  by  giving  the  latter  alone. 

There  are  some  feeble  children  and  some  cases  of  atonic  dyspepsia 
and  of  persons  with  but  limited  nervous  energy  for  whom  it  is  bet- 
ter to  prescribe  alcohol  half  an  hour  or  more  before  eating  in  order 
that  its  stimulating  influence  may  be  felt  in  the  system  before  the 
nervous  forces  are  called  upon  for  digestive  functions. 


2i8  STIMULANTS,   BEVERAGES,    CONDIMENTS. 

Selection  of  the  Proper  Fornv  of  Alcoholic  Beverage.— 

In  all  severe  cases  in  prescribing  alcohol  it  is  a  rule  that  the  stomach 
is  much  less  likely  to  be  upset  by  adhering  to  a  single  form  of  bever- 
age than  by  making  frequent  changes.  Persons  having  robust  phy- , 
siques  may  be  able  to  assimilate  several  kinds  of  wines,  including 
champagne,  at  dinner,  followed  by  liquors  and  brandy;  but  these 
beverages,  if  taken  in  such  variety  without  food,  will  almost  in- 
variably derange  the  stomach,  and  the  unpleasant  after-effects  which 
characterise  even  moderate  overindulgence  in  this  respect  are  usu- 
ally more  decided  if  a  variety  of  beverages  have  been  used  than  if 
only  one  kind  has  been  taken.  The  combination  of  whisky  and 
beer  or  strong  liquors  and  champagne  will  promptly  disagree  with 
many  persons  who  could  take  either  form  of  alcohol  alone  with 
impunity.  In  fever  the  stomach  is  always  temporarily  enfeebled, 
and  the  importance  of  adhering  to  one  simple  form  of  alcohol  is 
emphasised.  It  may  be  changed  from  time  to  time  in  conformity 
with  the  taste  of  the  patient,  but  mixtures  of  beverages  should  never 
be  given. 

With  persons  who  are  disposed  to  irritating  coughs  the  use  of 
malt  liquors  sometimes  increases  the  difficulty,  whereas  strong 
liquors  and  wines  may  prove  beneficial.  Beer,  ale,  porter,  stout,  etc., 
cannot  be  drunk  by  some  people  without  producing  a  subsequent 
feeling  of  lassitude  and  drowsiness  with  headache  and  suffusion  of 
the  face,  and  yet  diluted  spirits  may  be  well  borne.  Some  individ- 
uals find  that  sherry  produces  acid  dyspepsia,  and  others  find  that 
different  sweet  wines,  such  as  port,  similarly  disagree,  and  in  others 
again  they  excite  attacks  of  gout.  When  porter,  ale,  or  stout  do 
not  derange  the  stomach,  they  may  be  advantageously  used  by  those 
who  suffer  from  exhausting  discharges  or  by  women  who  are  weak- 
ened by  prolonged  suckling.  Alcohol  should  be  emphatically  for- 
bidden in  all  forms  of  gonorrhoea  and  syphilis,  and  a  single  infringe- 
ment of  this  rule  may  often  aggravate  the  complaint.  Some 
clinicians  prefer  the  use  of  wines  which  are  well  charged  with  vola- 
tile compound  ethers  as  a  stimulant  for  enfeebled  heart  action  and 
weak  digestion.  The  use  of  beer  as  a  beverage  for  fevers  is  more 
common  in  Continental  Europe  than  in  the  United  States.  If  there 
is  no  tendency  to  flatulent  dyspepsia,  it  may  sometimes  be  used  with 
advantage  in  such  cases,  when  it  will  slake  the  thirst  which  is  not 
quenched  by  other  drinks. 

As  a  preventive  of  drunkenness  and  the  evils  of  chronic  alcohol- 
ism the  introduction  of  the  milder  malt  liquors  into  this  country  to 
partially  supersede  the  use  of  strong  spirits  has  proved  a  decided 
advantage.  The  extent  to  which  this  is  taking  place  is  strikingly 
illustrated  by  the  following  data,  compiled  by  United  States  Com- 
missioner Clark : 


STIMULANTS   AND   BEVERAGES. 


219 


"  The  consumption  per  capita  [in  the  United  States]  of  all  wines 
and  liquors  was  : 

6.43  gallons  in  i860 
7.69       "         "   1870 
10.09       "         "   1880 
13.86       "         "   1889. 
"  The  consumption  of  distilled  liquors  per  capita  has  gradually 
declined  from  2.86  gallons  in  i860  to  1.25  gallon  in  1889.      That 
of  wines  has  gradually  increased  from  0.39  gallon  in  i860  to  0.53 
gallon  in  1889,  and  that  of  malt  liquors  from  6.43  gallons  in  i860 
to  12.68  gallons  in  1889." 

At  the  beer  brewery  of  the  Anheuser  Busch  Company,  in  St. 
Louis,  which  is  the  largest  establishment  of  the  kind  in  the  world, 
upward  of  half  a  million  barrels  of  beer  are  produced  annually. 

Italy,  France,  and  Spain  grow  two  thirds  of  the  world's  wine, 
and  in  France  the  annual  consumption  of  spirits  is  only  3.80  litres 
per  capita. 

Malt  Liquors. 

BEER. 

The  lager-beer  industry  was  introduced  into  this  country  about 
the  year  1842.  In  1890  nearly  twenty-seven  million  barrels  of  malt 
liquors  were  produced  in  the  United  States,  and  the  per  capita  con- 
sumption of  beer  in  New  York  State  alone  was  estimated  at  one 
hundred  and  twenty-four  quarts  per  year. 

Composition. — Beer  contains  alcohol  in  strength  varying  be- 
tween 3  and  8  volumes  per  cent  (sometimes  even  10  per  cent).  As 
an  average,  in  round  numbers,  a  pint  of  good  beer  contains  an 
ounce  of  alcohol.  Besides  this  alcohol  and  much  water,  beer  con- 
tains a  variety  of  ingredients,  such  as  bitter  and  resinous  extractives 
from  hops,  sugar,  dextrin,  albuminates,  glycerin,  free  acids,  and  ash — 
the  latter  only  as  a  trace.  The  sugar  of  beer  is  fattening,  and  the 
bitter  matter  is  more  or  less  of  a  stomachic  tonic. 

By  process  of  manufacture  much  beer  is  made  to  contain  only 
water,  alcohol,  and  bitter  principles.  Hop  extracts  possess  a  nar- 
cotic influence,  and  hence  beer  may  give  rise  to  drowsiness,  whereas 
other  alcoholic  beverages — like  champagne  or  whisky — prove  enliv- 
ening.    This  effect  is,  however,  quite  variable. 

Beer  produces  biliousness  in  persons  of  weak  digestion.  It  is 
sometimes  called  "  fluid  bread,"  but  the  expression  conveys  a  wholly 
exaggerated  idea  of  its  food  value,  although  it  is  certainly  fattening 
when  drunk  in  large  quantity. 

Beer  Brewing. — Malt  is  the  name  given  to  any  germinating 
cereal,  but  to  prepare  it  for  beer  brewing,  malt  is  made  from  barley 
grains  as  follows :  The  grain  is  steeped  in  water  at  a  temperature 


220  STIMULANTS,    BEVERAGES,   CONDIMENTS. 

which  causes  germination  and  the  development  of  diastase.  It  is 
next  couched  and  "  floored,"  during  which  process  germination  con- 
tinues, and  it  is  finally  kiln-dried. 

Brewing  of  beer  is  accomplished  as  follows :  The  prepared  bar-^ 
ley  malt  is  first  cleaned  by  screening,  sifting,  and  blowing,  is  crushed 
and  then  "  mashed  "  or  infused  with  water  in  large  tubs  at  a  proper 
temperature.  This  process  extracts  the  existing  sugar  and  dextrin 
and  aids  in  converting  the  residue  of  starch  into  maltose  and  dex- 
trin. The  "  wort  "  t|ius  formed  is  a  solution  of  diastase,  dextrin, 
sugar,  proteids,  and  salts.  It  is  drawn  off,  and  the  residue  of  grain 
is  washed  with  hot  water  by  a  process  called  "  sparging,"  which 
extracts  any  remaining  useful  material.  ^The,^  wort  is  run  into  cop- 
per kettles  and  boiled  for  about  four  hours.  During  the  last  hour 
hops  are  poured  in.  The  boiling  concentrates  the  wort,  extracts 
the  hop  essence  or  lupulin  with  tannin,  causes  coagulation  and  pre- 
cipitation of  any  albuminous  matter,  and  finally  it  checks  further 
fermentation  for  the  time  being.  The  wort  is  next  cooled  and  yeast 
is  added  in  the  proportion  of  about  a  pound  to  the  barrel.  The 
yeast  sets  up  a  new  fermentation,  which  converts  the  saccharine 
substances  into  alcohol  and  carbon-dioxide  gas.  This  fermentation 
is  retarded  by  continued  application  of  cold.  When  it  is  concluded, 
the  beer  is  drawn  into  settling  tuns,  and  then  into  casks,  where  it  is 
stored  from  five  to  eight  months,  after  which  it  is  ready  for  bottling. 
While  resting  in  the  casks  the  beer  is  subjected  to  "  fining  "  — i.  e., 
beech-tree  shavings  are  added  to  it,  to  collect  any  floating  solid 
particles.  This  process  allows  so  much  carbonic  acid  to  escape  that 
a  second  fermentation  is  sometimes  set  up  by  adding  new  beer  to 
the  old  in  the  proportion  of  i  to  5. 

Beer  which  is  kept  long  fermenting  increases  in  alcohol  and  di- 
minishes in  extractives.  Its  natural  intensity  of  colour  varies  with 
the  method  of  drying  the  malt,  and  increases  with  long  boiling. 

White  beer  is  brewed  from  wheat  instead  of  rye.  It  is  less  clear 
than  rye  beer,  paler,  and  more  frothy  and  sour. 

The  low  Bavarian  beer  is  fermented  by  a  variety  of  saccharo- 
myces,  which  acts  at  a  temperature  of  6°  to  8°  C.  (Pasteur). 

Certain  varieties  of  saccharomycetes,  acting  at  different  tem- 
peratures, set  up  undesirable  fermentation  in  both  beer  and  wine, 
making  them  sour,  and  developing  peculiar  odours. 

Ale. — Ale  is  made  from  pale  malt  by  processes  resembling  the 
brewing  of  beer.  It  contains  from  3  to  6  per  cent  of  alcohol. 
Strongly  alcoholic  ales  are  less  used  than  formerly,  having  been 
largely  supplanted  by  the  lighter  varieties  and  by  beer.  The  amount 
of  hops  used  determines  the  bitterness  of  the  ale,  and  their  aromatic 
bitter  principles  furnish  the  peculiar  flavour.  Bitter  ale  has  been  so 
far  fermented  as  to  contain  but  little  sugar. 


STIMULANTS   AND   BEVERAGES.  221 

Porter. — Porter  is  made  from  pale  malt  with  the  addition  of  high 
dried  malt,  which  gives  it  colour  and  flavour.  It  contains  about  6 
per  cent  of  alcohol,  and  is  regarded  as  more  digestible  than  ale  of  the 
same  alcoholic  strength  (Pavy),  Both  ale  and  porter  contain  sugar 
and  acid,  but  these  substances  are  present  in  less  degree  in  malt 
liquors  than  in  wines. 

Stout. — Stout  is  similar  to  porter,  but  is  characterised  by  a  pre- 
ponderance of  extractives. 

The  stronger  malt  liquors,  such  as  porter,  stout,  and  heavy  ales, 
are  nutritive  and  fattening. 

All  stale,  flat  malt  liquors  without  a  "head  "  are  apt  to  nauseate 
and  prove  unwholesome. 

WINE. 

Composition. — Wine  made  from  the  expressed  juice  of  different 
varieties  of  the  grape  consists  of  an  alcoholic  solution  varying  in 
strength  from  6  to  25  volumes  per  cent,  and  containing  flavouring 
and  other  substances. 

The  maximum  normal  percentage  of  alcohol  which  fermenting 
grapes  are  capable  of  developing  is  not  above  15  per  cent,  but  alco- 
hol is  often  added  to  equal  18  or  25  per  cent  or  more. 

The  pulp  of  the  grape  furnishes  sugar  for  fermentation  of  alcohol, 
and  also  organic  acids  or  their  salts,  such  as  citrates,  malates,  and 
tartrates.  The  stones  or  seeds  furnish  essential  oils,  some  of  which 
give  the  "  bouquet "  of  volatile  ethers,  and  the  skins  and  stems  fur- 
nish pigments  and  tannin.  The  latter  is  preservative;  it  precipitates 
albuminous  substances  and  prevents  mouldiness.  The  chief  pigment 
of  wines  is  primarily  of  a  blue  colour,  but  it  is  reddened,  like  litmus, 
by  free  acid,  more  or  less  of  which  is  always  present. 

The  fermentation  of  wines  is  caused  by  germs,  which  exist  upon 
the  stems  or  skins  of  the  grapes. 

Besides  water,  sugar,  alcohol,  volatile  ethers,  and  carbonic  acid 
are  added  in  the  manufacture  of  the  different  kinds  of  wine. 

Leoser  gives  the  following  list  of  minor  substances,  traces  of  which 
are  more  or  less  constantly  present  in  wines :  "  Gelatin,  gum,  fat, 
wax,  albumin,  gluten,  tartaric  acid,  potassic  tartrate,  racemic  acid, 
malic  acid,  calcic  malate,  oxide  of  manganese,  oxide  of  iron,  potas- 
sium sulphate,  sodium  chloride,  calcium  phosphate,  magnesia,  silicic 
acid,  tannic  acid." 

The  composition  of  the  subtle  substances  which  impart  the  flavour 
and  aroma  or  bouquet  to  different  wines  is  unknown.  Most  of 
these  substances  develop  during  fermentation,  but  a  few  grapes,  such 
as  the  Muscatel,  yield  their  own  aroma  to  the  wine. 

According  t,o  Konig,  the  average  percentage  composition  of  grape 
must  is  water,  74.49;  sugar,  19.71;  nitrogenous  material,  0.28;  non- 
nitrogenous  material,  4.48;  ash,  0.40;  acid,  0.64. 


222  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

The  sugar  fluctuates  sometimes  as  much  as  24  per  cent  and  the 
acid  1.2  per  cent,  and  these  substances  usually  stand  in  inverse  pro- 
portion to  each  other. 

General  Properties. — The  perfected  wine  has  the  properties  of 
colour,  "  body  "  or  substance,  and  flavour,  aroma,  bouquet,  or  "  fruiti-" 
ness."  Different  wines  are  valued  for  their  astringency  (tannin), 
sweetness  (grape  sugar),  strength  (alcohol),  acidity  (organic  acids), 
colour  or  sparkle,  flavour,  and  ability  to  stimulate  the  appetite  and 
digestion.  V_3 

Fermentation. — Wines  are  both  naturally  and  artificially  fermented, 
and  many  varieties  are  re-enforced  by  flavouring  extracts  and  forti- 
fied by  addition  of  alcohol.  The  latter  method  has  the  twofold  ef- 
fect of  adding  to  their  strength  and  of  preserving  them  from  further 
fermentation,  and  hence  is  used  especially  for  the  wines  of  the  Cape, 
Maderia,  and  Portugal.  In  the  cooler  climate  of  France,  Germany, 
and  Hungary  fermentation  proceeds  more  slov^iy  and  fortification  is 
less  necessary,  for  the  wines  of  these  countries  are  drier,  less  fruity, 
and  require  less  time  to  mature.  They  also  have  stronger  bouquet, 
because  they  possess  more  acid,  which  combines  with  alcohol  to  fur- 
nish the  aroma  (Pavy). 

Sugar. — The  quantity  of  sugar  present  in  wines  varies  consider- 
ably. It  is  sometimes  almost  completely  eliminated  by  fermentation 
into  alcohol,  or  it  may  be  added  in  excess  to  make  the  natural  flavour 
sweeter. 

Flavour  and  Bouquet. — Some  Greek  wines  have  a  peculiar  flavour, 
the  liking  for  which  is  an  acquired  taste.  This  flavour  is  derived 
from  rosin  contained  in  the  wood  of  casks  used  for  preserving  the 
wines,  which  induces  chemical  changes. 

The  Hungarian  wines  have  agreeable  fruitiness,  but  they  are  not 
so  completely  ripened  as  French  wines,  and  are  hence  more  apt  to 
turn  sour  when  transported. 

Both  glucose  and  saccharose  can  be  oxidised  into  acids  instead 
of  fermenting  to  alcohol,  and  when  this  process  occurs  extensively 
in  a  wine  it  becomes  sour,  like  vinegar,  and  is  unfit  for  consump- 
tion. 

In  general  the  flavour  and  bouquet  of  a  wine  depend  upon  (i)  the 
nature  of  the  soil  in  which  the  grape  is  grown,  (2)  the  climate  and 
temperature,  (3)  the  quality  of  the  grape,  (4)  the  use  of  but  a  single 
variety  of  grape  for  a  given  wine,  (5)  the  ripeness  of  the  grape,  (6) 
the  duration  of  fermentation,  (7)  the  addition  or  subtraction  of  ma- 
terial by  the  art  of  the  wine  grower,  (8)  the  age  of  the  wine. 

In  vineyards  where  the  best  wines  are  made  the  grapes  are  tested 
from  day  to  day  to  determine  the  right  time  to  pick  the  vines,  for 
the  quantity  of  sugar  and  acid  present  depend  upon  the  degree  of 
ripening  and  influence  the  flavour  of  the  wine. 


STIMULANTS  AND  BEVERAGES. 


223 


White  Wines. — White  wine  is  made  from  grapes  of  any  colour, 
the  greatest  care  being  taken  not  to  macerate  the  berries  in  express- 
ing the  juice,  and  to  allow  no  coloured  juice  to  flow.  As  a  rule, 
however,  the  better  class  of  white  wines  is  made  from  selected  white 
grapes,  which  are  crushed  with  their  skins.  The  mass  is  left  for  sev- 
eral days,  so  that  the  skins  may  impart  what  little  soluble  matter  they 
contain  to  the  pulp.  The  juice  is  then  obtained  by  further  pressure 
and  allowed  to  ferment.  The  crushing  of  grapes  was  formerly  done 
by  the  feet  of  men  who  trampled  upon  them,  but  several  lives  were 
lost  by  carbonic-acid  poisoning,  and  the  process  is  now  generally 
conducted  by  machinery. 

After  several  months,  or  longer,  the  ferment  and  the  salts  which 
are  insoluble  settle  in  a  sediment  called  lees,  and  the  supernatant 
fluid  is  carefully  drawn  off  and  casked  or  bottled. 

During  the  first  year  or  so  of  storage  some  wines  are  recasked 
several  times,  for  they  continue  to  deposit  lees  on  the  bottom  and 
sides  of  the  cask,  consisting  mainly  of  "  argol,"  an  acidulous  salt  from 
which  cream  of  tartar  may  be  prepared. 

When  fermentation  has  proceeded  long  enough  it  is  stopped, 
according  to  the  nature  of  the  wine,  by  the  addition  of  alcohol  or 
strong  sugar  solution,  or  if  left  to  continue  after  the  wine  is  stored, 
the  sugar  and  extractives  very  gradually  disappear,  and  alcohol  con- 
tinues to  develop. 

Hence  if  a  wine  can  be  bottled  early  without  being  too  green  or 
immature  it  is  sometimes  a  decided  advantage,  for  more  of  the  aroma 
and  flavour  may  be  thus  retained. 

In  other  cases  wines  should  remain  in  the  casks  for  from  one 
to  four  years  before  bottling — the  more  delicate  varieties  being  kept 
the  longest — for  certain  changes  depend  upon  the  size  and  nature  of 
the  containing  receptacle,  which  are  checked  by  bottling.  Pavy 
says :  "  By  keeping  in  a  cask,  wine  increases  in  alcoholic  strength. 
This  is  to  be  accounted  for  by  wood  being  more  easily  penetrated 
by  water  than  by  alcohol.  Thus  it  happens  that  water  is  lost  by 
evaporation  from  the  outside  of  the  cask  in  larger  quantity  than 
the  alcohol,  and  the  wine  is  left  in  a  more  concentrated  condition." 

White  wines  are  produced  in  more  variety  than  red  wines.  On 
the  average  they  contain  from  9  to  12  per  cent  of  alcohol,  from 
0.30  to  0.50  per  cent  of  sugar,  and  about  0.50  per  cent  of  acid. 

Red  Wines. — In  making  red  wine  dark  grapes  are  used,  and 
both  skins  and  stones  are  left  to  ferment  with  the  pulp,  to  which 
they  furnish  tannin,  pigment,  and  extractives. 

Red  wines,  on  the  average,  contain  from  8.5  to   11   per  cent  of 
alcohol,  0.55  to  0.65  per  cent  of  acid,  and  0.15  to  0.20  per  cent  of 
tannin  and  pigment.     The  red  wines  are  as  a  rule  more  easily  di- 
gested than  white,  and  are  more  nutritive. 
17 


224  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

The  following  practical  statements  are  quoted  from  Leoser,  in 
the  Report  of  the  United  States  Commission  at  the  Paris  Exposi- 
tion of  1889: 

"Bottled  red  wines  that  are  rich  in  tannic  acid,  like  port,  for 
instance,  deposit  a  sediment  and  grow  lighter  in  colour.  Those 
that  contain  less  tannic  acid  generally  grow  darker.  The  cause  of 
this  is  a  gradual  diminution  in  the  quantity  of  free  acid  in  the  wine, 
The  effect  of  this  acid  is  to  turn  the  colouring  matter  red,  and  as  it 
diminishes,  therefore,  the  wine  grows  darker  or  more  purple." 

Red  wine  (claret)  is  often  drunk  diluted  with  Vichy,  when  "  the 
potassium  carbonate  of  the  water  saturates  the  free  acid  of  the  wine, 
and  so  destroys  the  red  colour  and  permits  it  to  become  darker, 
while  the  action  of  the  alkali  upon  the  colouring  matter  gives  it  a 
cloudy  appearance." 

The  deeper  the  colour  the  rougher  is  the  flavour  of  the  wine  in 
most  cases. 

"  If  two  wines  of  equal  alcoholic  strength  be  taken  it  will  be 
found  that  equal  doses  of  each  will  produce  their  effect  much  more 
quickly  in  the  case  of  the  white  wine  than  in  that  of  the  red.  The 
reason  of  this  is  that  the  astringent  action  of  the  tannic  acid 
retards  the  effect  of  the  alcohol  upon  the  organism.  It  may  be 
that  this  indicates  in  a  general  way  the  superiority  of  white  wines 
as  stimulants  and  red  wines  as  tonics." 

Various  substances  are  used  for  "  fining  " — that  is,  to  clarify  wine 
— such  as  cream,  milk,  blood,  solutions  of  egg  albumen,  gelatin,  isin- 
glass, nutgalls,  lime,  etc.  Their  effect  is  largely  mechanical,  but 
the  alkalies  neutralise  part  of  the  acids. 

Other  substances  are  occasionally  employed,  having  in  view  the 
better  preservation  of  wine,  but  many  of  these  are  unhealthful  in 
their  effects  on  the  system.  Such,  for  example,  is  the  use  of  calcium 
sulphate,  which  is  converted  into  potassium  sulphate,  or  the  use  of 
alum,  sulphuric  or  other  acids,  etc.  Impure  alcohol  holding  fusel 
oil  is  sometimes  added.  The  object  of  storing  wine  in  enormous  tuns 
is  to  diminish  the  surface  exposed  to  the  air  in  comparison  with  the 
bulk. 

THE   VARIETIES   OF   WINES. 

The  following  classification  of  wines,  with  the  examples  and 
comments,  is  largely  derived  from  Chambers,  and  will  be  found 
convenient  and  practical  from  a  purely  dietetic  standpoint. 

Wines  may  be  classed  as — 

I.  Strong  Dry  Wines.  II.  Strong  Sweet  Wines.  III.  Aromatic 
Wines.  IV.  Acid  Wines.  V.  Sparkling  Wines.  VI.  Perfect  Wines. 
VII.  Rough  or  Astringent  Wines. 

I.  Strong  Dry  Wines  are  those  in  which  the  sugar  of  the  ex- 
pressed grape  juice  or  *'must"  has  fermented  into  alcohol,  either 


STIMULANTS  AND   BEVERAGES. 


225 


by  process  of  time  or  by  artificial  means.  When  left  to  itself,  this 
alcoholic  fermentation  is  extremely  slow,  occupying  many  years 
before  its  completion,  but  the  natural  process  is  better  than  any 
artificial  one  yet  discovered.  These  wines  also  contain  considerable 
alcohol,  often  17  or  18  per  cent,  which  makes  them  less  available  for 
general  dietetic  uses  than  weaker  wines.  Examples  are  strong,  dry 
old  sherry,  port,  Madeira,  and  Johannisberg.  (The  name  "  sherry  " 
is  often  used  as  a  generic  term  for  white  wines  grown  in  Spain.) 

These  wines,  especially  sherry,  are  sometimes  used  for  stimula- 
tion in  fevers  or  other  diseases,  in  lieu  of  spirits,  where  the  taste  of 
the  latter  is  strongly  disliked.  If  drunk  too  freely  they  congest  the 
stomach,  and  have  the  evil  effects  of  strong  spirits  or  of  strong 
alcohol  in  general  (see  Alcohol,  Evil  Effects).  They  often  contain 
some  sugar,  and  taken  with  meals  they  may  interfere  with  digestion, 
causing  acetic  fermentation,  and  especially  disturbing  the  digestion 
of  fats. 

Port  is  a  wine  in  which  the  original  fermentation  has  been 
arrested  by  the  addition  of  alcohol,  and  it  has  a  proverbially  bad 
reputation  for  precipitating  attacks  of  the  gout.  In  England,  where 
much  more  is  consumed  than  here,  it  is  even  held  responsible  for 
causing  the  disease. 

It  is  well  known  that  port  improves  more  by  long  rest  in  the 
bottle  than  does  any  other  wine.  It  is  a  useful  temporary  tonic, 
and,  like  claret,  its  astringency  makes  it  serviceable  in  diarrhoeal 
diseases,  but  many  persons,  especially  in  this  country,  find  it  alto- 
gether too  heavy  for  daily  use.  This  is  not  altogether  due  to  its 
high  percentage  of  alcohol,  for  a  greater  quantity  of  strong  spirits 
will  sometimes  be  found  to  do  less  damage.  It  is  a  poor  wine  for 
dyspeptics,  and  should  be  proscribed  in  all  bilious  states,  lithiasis, 
cases  with  tendency  to  gallstone  formation,  gravel,  gout,  and  rheu- 
matism. It  has  been  largely  replaced  by  claret  of  late  years  as  a 
dinner  wine. 

Port  as  well  as  Burgundy  is  sometimes  spiced  or  "  mulled," 
and  prescribed  diluted,  as  a  tonic  for  elderly  people.  Taken  before 
retiring,  with  a  biscuit,  or  mixed  with  a  light  gruel,  it  may  promote 
their  sleep. 

II.  Strong  Sweet  Wines  are  those  which  contain,  either  nat- 
ural or  artificially  added,  fruit  sugar  in  sufficient  quantity  to  exer- 
cise a  preservative  influence,  and  further  fermentation  is  checked  by 
boiled  grape  juice.  Examples  are  Tokay,  Malaga,  sweet  sherry, 
sweet  champagne.  Malmsey,  Madeira,  Lachrymae  Christi,  and  other 
vins  de  luxe.  They  are  much  too  sweet  to  be  drunk  in  quantity,  but 
this  quality  is  sometimes  made  to  disguise  the  bitterness  of  other 
substances,  as  when  Tokay  is  added  to  coca  extract  to  make  "wine 
of  coca."     If  long  kept,  the  sweetness  is  reduced  but  the  peculiar 


226        STIMULANTS,  BEVERAGES,  CONDIMENTS. 

agreeable  flavour  remains.  Alcohol  may  be  added  to  further  insure 
preservation  and  increase  the  strength  of  the  wine,  and  sweet  port  is 
sometimes  made  in  this  manner. 

The  sweet  heavy  wines,  such  as  sweet  port,  sherry,  Madeira,  con- 
tain about  19  to  22.5  per  cent  of  alcohol,  3.5  to  6  per  cent  of  sugar, 
and  about  0.50  per  cent  of  acid.  Malaga  and  Tokay  contain  more 
sugar  and  less  alcohol. 

The  chief  use  of  these  wines  is  not  for  tonic  or  dietetic  purposes, 
but  for  their  agreeable  flavour.  They  are  better  taken  between 
meals,  if  at  all,  both  because  the  delicacy  of  their  flavour  is  more 
appreciated  when  the  mouth  is  free  from  other  tastes  and  because 
their  sweetness  may  interfere  with  digestion.  Like  all  sweet  wines, 
they  must  be  forbidden  to  the  gouty,  rheumatic,  bilious,  lithaemic,  and 
dyspeptic. 

III.  Aromatic  Wines  have  a  peculiarly  choice  bouquet,  and 
contain  abundance  of  essential  oils  with  considerable  alcohol.  They 
are  best  when  drunk  in  their  native  countries — in  Spain,  France,  Italy, 
etc. — for  they  bear  transportation  poorly  unless  re-enforced  by  addi- 
tional alcohol,  which  detracts  from  their  delicacy  of  flavour  and 
aroma.  Examples  are  the  choicer  Rhine  wines.  Moselle,  Capri,  Cha- 
teau-Yquem,  and  Orvieto.  Some  wines  of  this  class  are  "  more  noted 
for  their  acid  than  aroma"  (Chambers).  Such  are  white  Burgundy 
(Chablis)  and  white  Bordeaux  (Sauterne),  which  are  often  drunk 
with  salads  and  rich  foods.  The  Moselle  and  Rhine  districts  produce 
acid  grapes  with  abundant  aroma,  and  the  wines  which  bear  these 
names  are  many  of  them  almost  free  from  sugar. 

IV.  Acid  Wines  owe  their  distinguishing  property  to  tartaric 
acid  chiefly,  but  wines  which  have  turned  sour  on  keeping  or  by  ex- 
posure to  the  air  contain  acetic  acid  and  resemble  vinegar. 

V.  Sparkling  Wines  are  those  in  which  carbon-dioxide  gas, 
formed  by  fermentation  after  the  wine  is  bottled,  is  set  free  upon  un- 
corking, and  continues  to  be  liberated  for  some  time  thereafter.  The 
gas  gives  additional  flavour  to  the  wine  and  increases  its  exhilarating 
effect.  Such  wines  are  champagnes,  sparkling  Moselle,  and  vino 
d'Asti.  The  better  the  wine,  the  longer  it  continues  to  give  off  gas 
and  aroma  after  uncorking. 

These  wines,  especially  good  champagne,  are  very  serviceable  for 
invalids,  and  some  persons  with  delicate  stomachs  can  digest  no  other 
form  of  alcohol ;  but  poor  champagne  causes  gastric  derangement 
sooner  than  any  other  wine. 

When  nausea  and  vomiting  exist  they  have  special  power  for  al- 
laying the  gastric  irritation.  They  are  absorbed  with  great  rapidity, 
and  act  promptly  by  invigorating  the  nervous  system  and  circulation. 
They  may  sometimes  be  substituted  for  spirits  in  fevers  when  there 
is  need  of  alcoholic  stimulation.     Their  cost,  unfortunately,  places 


STIMULANTS   AND   BEVERAGES. 


227 


them  out  of  the  reach  of  many,  and  it  also  affords  much  temptation 
for  adulteration. 

Champag^ne. — The  essential  difference  between  champagne  and 
other  wines  is  that  it  contains  carbon-dioxide  gas  in  solution. 

Manufacture. — Champagne  is  made  of  different  grades,  represent- 
ing the  first,  second,  and  third  expressings  of  the  grape  juice  respect- 
ively.    It  contains  approximately  12  per  cent  of  alcohol,  or  less. 

Good  champagne  is  made  as  follows:  The  juice  is  allowed  to  fer- 
ment for  about  two  weeks,  when  it  is  poured  into  casks  and  kept  for 
a  period  varying  from  two  to  six  months,  after  which  it  is  bottled  and 
kept  from  two  to  nine  years  in  racks  arranged  to  hold  the  bottles  with 
their  mouths  down,  so  that  on  opening  them  all  sediment  which  has 
collected  in  their  necks  can  be  removed  or  "  degorged."  The  final 
process  is  the  addition  of  sugar-candy  sirup  dissolved  in  wine.  For 
the  ^'sec"  brand  8  per  cent  of  sirup  is  added;  for  other  brands  vary- 
ing quantities  up  to  16  per  cent  are  poured  in.  A  little  alcohol,  too, 
may  be  added,  after  which  the  wine  is  again  corked,  and  left  standing. 

Dryness. — Much  emphasis  is  placed  on  the  value  of  "  dry  "  cham- 
pagne for  invalids,  which  means  that  the  sugar  which  it  originally 
contained  has  disappeared,  and  hence  the  wine  is  less  apt  to  pro- 
duce flatulent  dyspepsia  or  aggravate  conditions  in  which  saccha- 
rine food  is  harmful.  True  "  dryness  "  is  the  result  of  age,  and  is 
due  to  a  very  slow  conversion  of  sugar  into  alcohol,  such  as  goes 
on  in  port  wine  which  has  been  kept  for  several  decades,  but,  as 
pointed  out  by  Chambers,  this  process  of  slow  ripening  does  not  re- 
munerate the  dealer,  so  he  induces  a  quicker  acetous  fermentation 
by  which  all  the  sugar  is  transformed  in  a  few  months,  instead  of 
many  years,  or  else  he  puts  but  half  the  quantity  of  sirup  into  the 
wine — 4  instead  of  8  per  cent.  It  is  champagne  manufactured  in  this 
manner  which  is  usually  shipped  out  of  France  for  foreign  consump- 
tion, and  hence  this  wine  often  has  a  "  dry  "  taste  because  it  is  sour, 
and  not  because  it  is  wholly  free  from  sugar.  When  this  is  the  case, 
it  imparts  a  bright-red  colour  to  blue  litmus,  even  after  the  free  car- 
bonic acid  which  it  contains  has  been  allowed  to  escape.  The  various 
brands  called  "dry,"  "extra  dry,"  or  ".f^^,"  ^^  ires  sec"  usually  rep- 
resent only  varying  degrees  of  acidity.  ^*  Brut"  refers  to  wines  left 
to  undergo  natural  fermentation. 

Undoubtedly  one  of  the  reasons  why  champagne  is  so  exhilarat- 
ing to  many  persons  is  the  fact  that  it  is  promptly  and  completely 
absorbed,  even  when  taken  with  food.  Its  effects  are  therefore 
suddenly  felt  by  the  nervous  system. 

VI.  "^  Perfect "  Wines  are  those  which  are  classified  by  Cham- 
bers as  having  their  several  ingredients — "  alcohol,  water,  sugar,  ethe- 
real flavours,  fruity  extractives,  and  acids " — commingled  without 
giving  characteristic  prominence  to  either  one.    Such  are  many  of  the 


228.  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

best  clarets,  but  the  red  wines  are  apt,  from  one  cause  or  another,  to 
fall  under  some  other  class. 

Bordeaux,  Burgundy. — The  best  Bordeaux  is  fully  fermented, 
but  the  commoner  Burgundies  and  red  Rhones  contain  "  too  much 
fruity  extractive,  which  decomposes  unless  re-enforced  by  alco- 
hol, and  are  unwholesome  unless  ripe  when  drunk "  (Chambers). 
When  a  red  wine  is  so  decomposed  it  is  unfit  for  consumption.  Re- 
fermentation  in  it  may  be  discovered  by  lightly  corking  a  half-filled 
bottle,  letting  it  stand  for  some  hours  in  a  warm  place,  and  then  shak- 
ing it.  If  carbonic  acid  is  present,  it  will  rise  in  bubbles  and  expel 
the  cork.  Wine  of  this  sort  deranges  digestion,  causing  acid  eructa- 
tions and  gastric  discomfort. 

Prime  Burgundies,  on  the  contrary,  like  Chambertin,  have  more 
"body,"  and,  because  they  contain  a  larger  percentage  of  alcohol,  do 
not  ferment.  Moleschott  gives  the  average  volumetric  percentage  of 
alcohol  in  red  wines  as  follows :  Clarets  or  red  Bordeaux,  10.61  ;  red 
Rhone,  10.39;  red  Burgundy,  11. 19. 

Therapeutic  Uses. — Prime  clarets,  Bordeaux,  and  Burgundies  are 
useful  tonics  for  invalids,  to  be  given  in  moderation  with  meals,  or 
in  some  cases  with  a  biscuit  or  light  sandwich  as  a  luncheon  between 
meals.  They  contain  little  or  no  sugar,  and  are  of  excellent  service 
in  convalescence  from  protracted  fevers,  such  as  typhoid,  or  from  the 
grippe,  etc.  The  lighter  forms,  if  of  good  quality,  are  the  best  form 
of  wine  for  daily  consumption  by  brain  workers  or  those  whose  seden- 
tary habits  or  whose  advanced  age  make  desirable  a  slight  stimulus 
to  appetite  and  digestion.  Claret  is  almost  the  only  wine  which  it 
is  at  all  safe  to  allow  gouty  or  diabetic  patients.  Of  red  Bordeaux, 
or  clarets,  Pavy  says : 

"  There  is  scarcely  any  condition  in  which  they  are  calculated  to 
disagree.  They  form  a  most  suitable  beverage  for  persons  of  a  gouty 
or  rheumatic  disposition,  and  also  for  the  dyspeptic.  It  may  be  said 
that  they  are  not  prone  to  turn  sour  upon  the  stomach  themselves, 
nor  to  cause  other  articles  to  become  sour ;  neither  do  they  provoke 
headache  or  derangement  in  those  who  are  subject  to  bilious  dis- 
orders." 

Burgundy,  being  a  much  fuller  wine  than  claret,  is  more  service- 
able where  anasmia  and  malnutrition  exist  if  it  can  be  borne  without 
giving  rise  to  headache. 

Beaujolais  is  intermediate  in  its  effects  between  claret  and  Bur- 
gundy. 

Some  years  ago,  when  scurvy  was  common  in  the  English  navy, 
it  was  found  that  the  substitution  of  red  wines  for  spirits  in  the 
ration  had  a  decided  prophylactic  influence. 

In  diarrhoea,  the  red  wines,  according  to  Lichtenstern,  have  a 
twofold  beneficial  action :  first,  by  depressing  exalted  reflex  excita- 


STIMULANTS   AND   BEVERAGES. 


229 


bility  in  visceral  nerves,  and,  secondly,  by  controlling  intestinal 
putrefaction.  Those  which  contain  considerable  tannin  are  also 
mildly  astringent. 

VII.  Rough  Wines  are  those  in  which  an  excess  of  tannin 
causes  decided  astringency.  They  usually  contain  pigment,  but  not 
much  alcohol.     Some  clarets  belong  with  this  group. 

As  a  rule,  these  wines  are  not  available  for  general  dietetic  or 
invalid  use,  and  are  mainly  employed  to  add  to  other  wines  to  aid 
in  their  preservation  and  otherwise  alter  them,  although  they  are 
drunk  by  the  peasants  in  the  countries  where  they  are  produced. 

Raisin  Wine. — An  inferior  quality  of  wine  is  made  by  restoring 
the  water  of  the  grapes  which  has  been  lost  by  drying  them  into 
raisins.  Wine  is  now  sometimes  made  in  France  from  raisins  dried 
in  California. 

Influence  of  Wines  upon  Digestion. — Roberts  has  thus  de- 
termined the  effect  of  several  wines  upon  peptic  digestion  by  adding 
together  two  grammes  of  dried  beef-fibre,  0.15  per  cent  of  hydro- 
chloric acid,  I  c.  c.  of  glycerin  extract  of  pepsin,  varying  proportions 
of  hock,  claret,  or  champagne,  and  water  to  100  c.  c. 


Proportion  of  Hock,  Claret,  or  Cham- 
pagne IN  THE  Digesting  Mixture. 


10  per  cent 
20    "       " 
40    "       " 
60    "       " 


.time  in  which  digestion  was  completed. 

(normal,    100  MINUTES.) 


Hock. 


100  minutes. 

115     " 
150     " 

Embarrassed. 


Claret. 


100  mmutes. 
140       " 
180       " 
Embarrassed. 


Champagne. 


go  minutes. 
100        " 
130 
180 


Liquors, 

Strong  spirits,  such  as  rum,  whisky,  brandy,  and  gin,  are  the 
worst  forms  of  alcohol  for  daily  drinking,  and  liquors  of  this  class 
are  responsible  for  nine  tenths  of  the  evils  of  inebriety.  In  locali- 
ties where  their  consumption  has  been  brought  into  competition  with 
or  has  been  superseded  by  that  of  beer,  drunkenness  has  often  di- 
minished. As  the  system  acquires  toleration  for  the  stronger  forms 
of  liquor,  it  is  found  that  its  desired  effects  can  only  be  obtained 
by  constantly  increasing  the  strength  or  the  frequency  of  the  drinks, 
and  meanwhile  the  alcohol  absorbed  is  gradually  converting  the 
different  tissues  of  the  body  into  pathological  specimens. 

The  drinking  of  new  and  raw  liquors  is  particularly  injurious, 
for  time  mellows  them  somewhat  and  reduces  the  quantity  of  their 
most  hurtful  ingredient — fusel  oil — while  their  flavour  improves. 
The  difference  in  taste  of  liquors  depends  upon  the  substances  from 
which  they  are  made  much  more  than  upon  any  skill  in  their  manu- 
facture or  modifications  in  their  fermentation,  circumstances  which 
so  materially  affect  wines. 


230 


STIMULANTS,  BEVERAGES,   CONDIMENTS. 


Brandy  and  other  strong  spirits  are  distilled  from  a  variety  of 
carbohydrate  foods,  such  are  potatoes,  corn,  rye  (whisky),  beets, 
rice  (arrack  and  sak^),  molasses  (rum),  crushed  grapes,  apples 
(applejack),  peaches,  plums,  cherries  {Kirsch),  and  other  fruits. 
These  spirits  contain  from  45  to  60  per  cent  of  alcohol,  besides  cane 
sugar  and  extractives. 

French  Cognac  is  a  strong,  pure  brandy,  distilled  either  from 
wine,  or  directly  from  crushed  grapes.  It  may  be  coloured  by  cara- 
mel.    Common  brandy  is  distilled  from  wine. 

Whisky. — American  whiskies  are  classed  as  (i)  rye  and  (2) 
Bourbon,  from  the  county  of  that  name  in  Kentucky. 

Manufacture. — The  proportion  of  materials  used  in  making  the 
"  mash  "  for  distillation  is,  on  the  average,  corn  meal  0.8,  rye  o.i,  and 
malt  0.1  (Leoser).  This  mixture  is  placed  in  tubs,  and  scalded  with 
"  slop,"  the  refuse  from  former  distillation.  After  cooling,  it  is 
raked,  or  mixed  by  a  stick  called  a  "  masher."  Water  is  added,  and 
the  mass  ferments  for  two  or  three  days. 

Sweet  mash  is  scalded  with  water  instead  of  slops,  and  yeast  is 
added  to  induce  fermentation. 

Sour-mash  whisky  is  made  without  yeast  but  with  slop.  The 
wort  is  then  heated  by  steam,  and  the  low  wines,  called  "  singlings," 
are  run  off  from  the  residue  or  slop  and  redistilled,  and  the  whisky 
is  ready  for  barrelling  (Leoser).  It  should  then  be  kept  from  three 
to  five  years  to  ripen,  according  to  the  details  of  its  manufacture. 

Pure  rye  whisky  is  distilled  by  an  identical  process,  but  the  corn 
is  wholly  replaced  by  rye. 

Scotch  and  Irish  whiskies  are  distilled  from  a  barley  mash. 

American  whiskies  are  kept  in  charred  barrels,  and  grow  darker 
from  colour  derived  from  the  wood  (Witthaus).  Scotch  whisky  de- 
rives its  colour  from  lying  in  old  sherry  casks. 

Proof  whisky  contains  equal  parts  of  absolute  alcohol  and  water. 

Leoser  says  :  "  The  difference  in  quality  in  different  kinds  of 
whisky  is  infinitesimal,  and  for  therapeutic  processes  may  be  neg- 
lected, provided  the  taste  of  the  patient  is  consulted." 

Gin  is  distilled  from  rye  mash,  and  flavoured  by  immersing  a 
bag  of  juniper  berries  in  the  vat  towards  the  completion  of  distil- 
lation. 

It  is  variously  known  under  the  names  Geneva,  Hollands,  and 
Schiedam,  the  two  latter  referring  to  its  Dutch  source,  the  former 
being  derived  from  the  French  word  for  juniper,  genievre,  of  which 
gin  is  a  corruption  (Pavy).  Gin  may  contain  17  per  cent  of  alcohol, 
but  it  is  often  diluted,  and  when  sweetened  besides,  it  is  known  as 
"  Old  Tom." 

Rum  is  distilled  from  a  mash  of  molasses.  The  wort  contains 
about   15  per  cent  of  sugar,  and  the  fermentation  process  requires 


STIMULANTS   AND   BEVERAGES. 


231 


from  nine  to  fifteen  days.  Rum  was  formerly  made  in  New  England, 
but  it  now  comes  chiefly  from  the  West  Indies,  and  that  made  in 
Jamaica  is  considered  the  best.  Other  rum  is  made  from  rectified 
proof  spirit.  It  is  a  liquor  which  improves  very  much  on  keeping 
for  several  years.  The  flavour  of  rum,  which  is  principally  due  to 
butyric  ether,  is  produced  by  adding  molasses,  caramel,  and  some- 
times fruits,  such  as  pineapple  or  guava.  Acetic  and  other  ethers 
are  also  present. 

Therapeutic  Uses  of  Liquors  Compared. — The  spirits  in 
common  use  have  different  physiological  action.  As  their  alcoholic 
basis  is  substantially  the  same  in  quality,  the  effects  are  varied 
mainly  by  aromatics.  Gin  is  the  most  distinctly  diuretic  of  the 
liquors.  Given  with  a  little  lemon  juice  and  diluted  with  some  effer- 
vescing water,  it  promptly  increases  the  urinary  secretion.  Brandy 
is  somewhat  more  astringent  than  whisky,  which  is  sometimes  laxa- 
tive. Brandy  is  therefore  to  be  preferred  in  cases  of  diarrhoea,  but 
in  this  country  at  least  it  is  very  apt  to  be  impure.  The  role  of 
liquors  as  tonics  and  stimulants  will  be  referred  to  under  the  heading 
of  the  different  diseases  in  which  they  may  be  required,  and  their 
influence  in  producing  alcoholism  is  discussed  under  that  heading. 
In  the  serious  illnesses  of  childhood,  such  as  diphtheria,  they  are 
well-nigh  indispensable,  and  in  such  cases  from  two  to  four  or  more 
ounces  of  whisky  or  brandy  may  be  given  (always  well  diluted)  to  a 
child  of  five  years  in  twenty-four  hours. 

Adulteration  of  Liquors  and  Wines.— Liquors  are  flavoured 
and  also  adulterated  by  a  variety  of  substances.  Among  those  men- 
tioned by  Chambers  as  oftenest  found  are  cocculus  indicus,  ginger, 
quassia,  wormwood,  caraway  and  coriander  seeds,  hartshorn  shav- 
ings, nux  vomica,  gentian,  alum,  cream  of  tartar,  chamomile,  juniper 
berries,  bitter  almonds,  orange  peel,  licorice,  honey,  rhatany,  and 
catechu.  ^ 

Much  of  the  cheapest  claret  sold  in  this  country  is  little  more 
than  a  decoction  of  logwood,  and  the  flavour  of  some  of  the  better 
grades  is  cleverly  imitated.  For  example,  Chateau-Latour  is  sophis- 
ticated with  almonds  or  other  nuts,  Chateau-Lafitte  with  violets  and 
nuts,  and  to  other  grades  cherry  juice  is  added.  Wines  are  often 
adulterated  with  artificial  pigments,  alum,  tannin,  fusel  oils,  cider, 
perry,  and  lime  salts. 

The  cheaper  grades  of  strong  liquors  contain  an  excess  of  fusel 
oil  or  amylic  ether,  which  is  not  an  adulterant  in  the  sense  that  it 
has  been  added  for  sophistication,  but  because  it  is  a  poisonous 
natural  product  which  is  difficult  to  eliminate.  It  is  responsible 
for  much  of  the  headache,  foul  tongue,  nausea,  dyspepsia,  and 
even  cirrhotic  changes  in  the  viscera  which  are  incident  to  dram 
drinking. 


232 


STIMULANTS,   BEVERAGES,   CONDIMENTS. 


Liqueurs  play  no  part  in  invalid  diet.  With  the  exception  of 
absinthe  and  Angostura,  they  contain  a  very  high  percentage  of 
sugar  with  essence,  and  they  all  have  a  large  proportion  of  alcohol. 
They  are  used  as  luxuries,  and  are  seductive  beverages,  for  their, 
agreeable  flavour  sometimes  begets  the  habit  of  alcoholism.  This 
is  especially  the  case  with  absinthe. 

Analysts  of  Liqueurs  (Rupp). 


lOO  C.  C.    LIQUEUR. 


Absinthe. . . 

Anise 

Kummel . . . 
Peppermint 
Angostura . . 
Cura9oa. . . . 
Benedictine 
Chartreuse. . 


Volume.  Weight. 


Per  cent. 
55-0 
40.0 
32-5 
35-0 
48.0 
52.5 
53-0 
44.0 


Per  cent. 
44.0 
32.0 
26.0 
28.0 

38.4 
42.0 
42.4 

35-2 


Extracts. 


Grammes. 
1.80 
33 -20 
29.80 
44.00 
12.00 
27.90 

35- 00 

35-40 


Sugar. 


Salts. 


Grammes. 
1. 10 
30.90 
28.20 
43.20 
7-50 
26.50 
33-40 

34-00 


Grammes. 
0.220 
0.310 
O.IOO 
0.090 
0.140 
0.075 
O.IIO 
0.091 


The  essences  are  distilled  or  expressed  from  aromatic  plants,  and 
such  colouring  agents  are  used  as  saffron,  cochineal,  indigo,  etc. 
Vermuth  contains  only  17  per  cent  of  alcohol. 

The  following  table  by  Duckworth  is  a  convenient  summary  of 
the  average  percentages  of  alcohol  in  round  numbers  in  the  different 
beverages  above  described : 


Spirits 35  to  44  per  cent. 

Port  wine 19  "       " 

Madeira 18   "       " 

Sherry 17  "       " 

Champagne Ii   "       " 

Burgundy 10  "       " 


Bordeaux 8  per  cent. 

Rhine  wines 8   "       " 

Porter 6  per  cent  or  more. 

Ale 3  to  6  per  cent. 

Cider 4  per  cent. 


Fig  Wine  is  made  in  countries  bordering  upon  the  Mediterranean, 
and  has  an  alcoholic  strength  of  between  7  and  8  per  cent.  It  also 
contains  considerable  mannite.  It  is  often  used  for  the  sophistication 
of  grape  wines. 

Cider. — Cider  usually  contains  from  4  to  8  volumes  per  cent  of 
alcohol  besides  malic  acid,  extractives,  sugar,  and  salts. 

It  is  slightly  laxative.  The  excess  of  carbonic  acid  generated  by 
cider  protects  it  from  the  atmospheric  air,  but  when  the  gas  dis- 
appears acetic  fermentation  converts  the  cider  into  vinegar. 

Cider  is  sometimes  made  from  condensed  apple  juice,  which  is 
added  in  the  proportion  of  one  part  to  twenty  of  water  when  ready 
for  use. 


CONDIMENTS  AND  SPICES.  233 

CONDIMENTS  AND  SPICES. 

Properties. — Condiments  and  spices  are  substances  which  are 
used  as  adjuncts  to  food,  and  which  in  themselves  supply  but  little 
nourishment,  their  effect  being  mainly  of  a  stimulating  character 
either  to  the  nerves  of  taste  or  secretion.  They  add  flavour  to 
otherwise  insipid  food,  and  relieve  monotony  in  diet.  Some  condi- 
ments, such  as  mustard,  contain  a  slight  amount  of  nutritious  mate- 
rial, but  the  total  quantity  of  any  of  them  which  can  be  taken  is  so 
small  in  comparison  with  the  bulk  of  the  food  that  they  may  hardly 
be  said  to  subserve  nutrition. 

Curry  powders  of  various  sorts  are  prepared  by  mixing  strong 
condiments,  such  as  Cayenne  pepper  and  ginger,  with  starchy  food 
and  turmeric. 

Some  foods  are  themselves  so  stimulating  to  the  mucous  mem- 
brane that  they  answer  the  double  purpose  of  food  and  condiment 
combined  ;  such,  for  example,  are  onions  and  garlic. 

In  the  mouth  condiments  produce  an  agreeable  taste,  with  an 
increased  -flow  of  saliva,  and  the  desire  for  food  in  the  stomach  is 
stimulated.     They  also  increase  the  secretion  of  gastric  juice. 

Uses. — In  some  dyspeptic  conditions  of  the  stomach  accom- 
panied by  local  sensation  of  weight  or  oppression,  or  even  of  pain, 
the  use  with  the  food  of  strong  condiments — such  as  mustard, 
Cayenne  pepper,  or  Tabasco — affords  relief  by  exciting  the  func- 
tional activity  of  the  stomach.  Cayenne,  in  fact,  is  a  favourite  in- 
gredient of  various  dinner  pills. 

With  the  exception  of  salt,  the  use  of  which  has  been  elsewhere 
fully  described  (page  39),  none  of  the  condiments  are  absolutely 
indispensable  in  the  sense  of  being  essential  for  prolonging  health, 
but  so  accustomed  are  all  classes  of  men  to  their  use  from  heredity 
or  personal  experience  that,  despite  the  aphorism  of  Plutarch  that 
"  hunger  and  salt  should  be  man's  only  sauce,"  without  other  rel- 
ishes the  appetite  soon  fails.  There  are  many  cases  of  feeble  diges- 
tion and  diminished  activity  of  the  gastric  juice  which  are  decidedly 
benefited  by  their  use  in  moderation. 

Harmful  Effects. — The  use  of  some  condiments  is  apt  to  be 
abused,  and  this  is  particularly  true  of  peppers,  curry,  pickles,  and 
vinegar.  If  consumed  habitually  in  excess,  these  substances  excite 
gastric  hypersemia  and  catarrh  by  overstimulation,  and  may  disorder 
intestinal  digestion  as  well.  They  at  first  cause  more  food  to  be 
eaten  than  necessary,  and  eventually  destroy  the  appetite,  develop- 
ing chronic  dyspepsia  of  an  aggravated  type.  Persons  living  in 
tropical  climates  where  food  and  service  are  cheap  are  apt  to  lead 
indolent  lives  and  indulge  too  liberally  in  the  pleasures  of  the  table, 
and  the  overloading  of  the  stomach  tempts  them  to  add  quantities 


234  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

of  condiments  to  their  food  for  the  purpose  of  stimulating  an  already 
overworked  digestive  system  to  the  performance  of  further  duty. 
The  heat  of  the  climate  prevents  active  exercise,  which  in  turn  re- 
duces the  oxidation  processes  of  the  assimilated  food.  The  rational 
diet  for  those  not  acclimated  to  the  tropics  should  consist  largely  of 
vegetables  and  fruits,  while  nitrogenous  food,  strong  condiments, 
spirits,  bitter  beer,  etc.,  should  be  carefully  shunned. 

Varieties  of  Flavouring. — Next  to  salt  (see  page  39),  the  most 
useful  condiments  are  pepper,  mustard,  ginger,  and  vinegar,  but  much 
difference  in  taste  exists  in  the  use  of  condiments,  and  their  selection 
is  to  some  extent  a  race  characteristic.  Thus  the  Persian  prefers  his 
asafoetida,  which  no  one  else  can  tolerate ;  the  Spaniard  and  Mexican 
his  garlic  ;  the  East  Indian  his  curry  ;  and  the  Frenchman  his  salad 
with  vinegar. 

From  long-continued  association  certain  condiments  appear  to  go 
best  with  definite  foods,  and  so  accustomed  are  most  persons  to  their 
combination  that  we  cannot  easily  recall  the  one  flavour  without  the 
other;  thus  mustard  is  associated  with  ham,  black  pepper  with  eggs, 
red  pepper  with  raw  oysters,  vinegar  with  spinach  and  raw  tomatoes, 
etc.,  and  when  deprived  of  the  usual  relish  the  food  tastes  insipid. 
Such  details,  insignificant  as  they  may  ordinarily  appear,  become  very 
important  for  certain  classes  of  invalids  in  whom  it  is  necessary  to 
preserve  the  appetite  by  pleasing  the  palate  in  order  that  they  may 
take  food  enough  to  sustain  them.  Such  are  cases  of  phthisis,  em- 
pyema, and  other  forms  of  chronic  wasting  diseases. 

Often  by  varying  the  flavouring  slightly  from  day  to  day  two  or 
three  times  as  much  of  the  same  food  will  be  taken  by  the  invalid.  A 
skilful  use  of  condiments  may  do  away  with  the  necessity  for  alco- 
holic stimulation  and  serve  a  better  purpose. 

Beef  tea  and  meat  broths,  which  become  wearisome  to  many  inva- 
lids, will  be  often  relished  if  a  taste  of  some  savoury  aromatic  herb  be 
added,  such  as  parsley,  thyme,  sage,  marjoram,  or  mint. 

Mustard  does  not  really  stimulate  the  gastric  secretion,  but  many 
persons  find  that  it  increases  the  appetite  somewhat,  and  it  often  pro- 
duces a  sensation  of  warmth  or  mild  burning  in  the  stomach  or  a  feel- 
ing akin  to  hunger.  It  is  used  to  advantage  in  moderation  in  salad 
dressings  or  with  cold  meat,  and  is  sometimes  serviceable  in  those 
cases  in  which  the  main  difficulty  is  a  lack  of  appetite  without  special 
enfeeblement  of  the  digestive  organs,  but  it  has  very  little  positive 
value,  and  while  its  use  in  health  may  be  left  as  a  question  of  indi- 
vidual taste,  it  is  scarcely  ever  to  be  specifically  recommended,  and 
its  abuse,  like  that  of  all  condiments,  may  give  rise  to  gastric  irrita- 
tion. The  general  irritating  effect  of  mustard  in  large  quantities  ap- 
plied to  the  skin  or  gastric  mucous  membrane  is  well  known,  and 
diluted  with  lukewarm  water  (a  teaspoonful  of  mustard  to  a  pint  of 


CONDIMENTS   AND   SPICES.  235 

water)  it  constitutes  a  very  prompt  and  valuable  emetic.  Mustard  is 
said  to  make  the  evacuations  of  the  bowels  somewhat  more  moist 
(Ringer).  The  seeds  are  sometimes  eaten  for  their  laxative  action. 
The  diuretic  effect  which  has  been  attributed  to  mustard  is  not 
established. 

Black  pepper  is  the  berry  of  a  plant,  the  Piper  nigrum,  which  grows 
in  the  West  Indies,  Sumatra,  and  other  Eastern  countries.  The  whole 
berry  is  dried  and  ground  for  use. 

White  pepper  is  made  from  the  same  berry  by  previously  soaking 
off  the  outer  husk  in  water.  About  thirteen  million  pounds  of  black 
pepper  are  annually  consumed  in  the  United  States.  It  is  often 
adulterated,  and  to  avoid  deception  it  may  be  purchased  in  corns 
and  freshly  ground  at  the  table. 

Cayenne  pepper  is  not  a  true  pepper,  but  is  made  from  the  crushed 
pod  of  various  species  of  Capsicum.  It  grows  in  the  tropics,  especially 
along  the  eastern  coast  of  Africa  and  in  Zanzibar. 

The  Capsicum  annuum  is  cultivated  in  this  country  for  the  making 
of  pickles  from  the  large  unripe  green  fruit. 

The  Capsicum  fastigiatum  is  a  variety  employed  medicinally,  and 
recognised  by  the  Pharmacopoeia. 

Chilies  is  a  common  name  given  to  this  pepper  in  England,  and 
chili  sauce  is  an  essence  prepared  from  it.  It  is  the  strongest  variety 
of  capsicum. 

Capsicum,  called  also  Cayenne  or  red  pepper,  like  mustard,  is  a 
strong  irritant  to  both  the  skin  and  the  mucous  membranes.  Over- 
doses of  it  excite  violent  local  inflammation  and  gastro-enteritis. 
Like  mustard,  it  is  doubtful  whether  capsicum  in  any  degree  pro- 
motes the  secretion  of  the  gastric  juice,  but  it  sometimes  stimulates 
a  flagging  appetite  and  produces  a  feeling  of  warmth  in  the  stomach  ; 
the  latter  readily  becomes  tolerant  to  increasing  doses  of  capsicum, 
and  it  is  found  that  more  and  more  is  required  by  those  who  have  to 
use  it  habitually  to  excite  the  accustomed  stimulation.  Its  chief  use 
is  as  a  substitute  for  alcohol  for  dipsomaniacs,  especially  where  the 
effort  is  being  made  to  stop  drinking  abruptly.  Its  fiery  nature  tem- 
porarily satisfies  the  craving  of  the  stomach.  When  chronic  alcoholic 
gastritis  exists,  the  stomach  digestion  is  often  improved  and  the  crav- 
ing to  satisfy  it  by  strong  liquor  may  be  relieved  by  the  tincture  of 
capsicum  given  in  doses  of  ten  or  fifteen  minims  diluted. 

The  use  of  capsicum  in  health  is  far  from  necessary,  but  it  forms 
an  agreeable  condiment  for  many  persons.  It  forms  an  ingredient 
of  many  dinner  pills  which  are  taken  by  elderly  people  with  inactive 
digestion  for  the  purpose  of  promoting  the  appetite. 

Red  pepper,  like  black,  is  often  adulterated.  When  pure  it  may 
be  entirely  suspended  in  water.  If  any  precipitate  falls  it  is  probably 
red  lead. 


236  STIMULANTS,   BEVERAGES,   CONDIMENTS. 

Capers  are  the  flower  buds  of  a  bush,  the  Capparis  spinosce,  which 
grows  in  Eastern  countries  bordering  on  the  Mediterranean.  They 
are  preserved  in  salt  and  vinegar,  and  are  used  for  flavouring  sauces 
for  mutton  and  other  foods.  They  contain  tannin,  volatile  oil,  yel- 
low pigment,  and  a  bitter  principle. 

Spices  are  solely  of  value  ir^-giving  variety  of  taste  to  the  food, 
and  hence  tempting  invalids  or  convalescents  with  lagging  appe- 
tites to  eat  more.  Comparatively  tasteless  food,  such  as  rice,  may 
be  made  very  attractive  by  spicing. 

For  children  the  most  useful  flavouring  substances  are  cinnamon 
and  ginger,  and,  although  not  a  spice,  vanilla  extract.  For  invalids 
there  maybe  added  nutmeg  and  cloves,  although  any  agreeable  spice 
may  be  used  in  moderation,  such  as  mace,  allspice,  cloves,  etc.  Pa- 
tients who  will  not  drink  hot  water  when  it  is  ordered  will  often  do  so 
if  they  can  steep  a  few  cloves  or  a  small  piece  of  cinnamon  in  it,  and 
this  can  rarely  do  harm.  Those  who  object  to  the  taste  of  milk 
punches,  custards,  and  simple  farinacous  foods  will  often  take 
these  substances  when  slightly  flavoured  with  a  trace  of  some  agree- 
able spice.  The  latter  as  ordinarily  used  for  flavouring  is  never 
injurious.  Only  in  large  doses  are  such  spices  as  those  above  men- 
tioned capable  of  such  irritant  action  in  the  stomach  as  may  be 
produced  by  curry  or  mustard. 

Ginger  is  useful  both  as  a  condiment  and  as  a  food.  It  is  the 
dried  root  of  the  Zinziber  officinale,  which  grows  in  Jamaica,  China, 
and  elsewhere.  The  rhizome  is  scraped  and  either  dried  and  pow- 
dered, or,  if  it  is  to  be  preserved,  it  is  washed  and  boiled  for  twenty- 
four  hours,  and  then  soaked  for  another  day  in  salt  water.  It  is 
then  washed,  sun  dried,  and  boiled  for  half  a  day  with  an  equal 
weight  of  sugar  (Clark).  It  is  placed  in  jars  for  several  days,  and 
then  once  more  boiled,  when  it  is  finally  sealed  in  jars.  It  is  excel- 
lent for  flavouring  rice  and  other  insipid  farinaceous  foods  for  con- 
valescents and  children. 

Vanilla  is  derived  from  vanilla  beans,  grown  in  Mexico,  Java, 
and  other  tropical  regions.  It  makes  an  agreeable  flavouring  ex- 
tract for  foods  for  invalids  and  children,  such  as  farinaceous  gruels, 
custards,  blancmange,  or  ice  cream,  for,  unlike  the  spices,  it  is  very 
bland.     Its  chief  use  is  in  the  manufacture  of  chocolate  (page  204). 

Vinegars  are  made  from  wine,  beer,  cider,  various  fruits,  and  even 
from  the  dry  distillation  of  wood.  They  contain,  besides  acetic 
acid,  traces  of  dextrin,  sugar,  organic  acids,  pigment,  extractives, 
and  acetic  ether. 

White  vinegar  is  the  best  in  taste  and  odour. 

The  acetic  acid  in  good  French  vinegar  exists  in  the  proportion 
of  5  per  cent.  Ordinary  table  vinegar  contains  between  2  and  7  per 
cent. 


CONDIMENTS   AND   SPICES. 


237 


The  acidity  enables  this  condiment  to  soften  muscle  fibre  so 
that  the  digestion  is  facilitated  of  tough  meat,  such  as  corned  beef, 
boiled  beef,  and  other  foods  with  hard  fibre,  like  salmon,  lobsters,  or 
hard-boiled  eggs. 

The  action  of  mild  acids,  such  as  vinegar,  favours  the  digestion 
of  tough  cellulose,  and  aids  the  formation  of  sugar.  For  this  reason 
vinegar  is  a  wholesome  addition  to  coarse,  fibrous,  or  stringy  vege- 
tables, such  as  beets,  cabbage,  spinach,  lettuce,  celery,  etc.,  and  to 
raw  vegetables,  such  as  cucumbers,  coleslaw,  lettuce,  and  like  ma- 
terials used  in  salads.  Vinegar  is  often  eaten  with  baked  beans,  but 
it  is  said  to  make  their  legumin  less  soluble  (Chambers).  If  vine- 
gar taken  in  a  salad  dressing  disagrees,  white  wine  may  be  substi- 
tuted with  pepper  or  mustard  and  oil. 

Vinegar  has  a  well-known  antiseptic  and  preservative  action,  and 
hence  its  use  for  pickling  fish,  oysters,  fruits,  and  vegetables. 

Pickles  are  indigestible,  and  should  take  no  part  in  an  invalid 
dietary. 

An  excess  of  vinegar  habitually  consumed  with  pickles,  or  other- 
wise, causes  anaemia  and  emaciation  by  lessening  the  number  of  red 
corpuscles  and  reducing  the  alkalinity  of  the  blood. 

Vinegar  is  often  adulterated,  or  spurious  articles  are  substituted 
for  it.  This  is  especially  true  of  that  used  for  the  cheaper  varieties 
of  pickles,  and  weak  sulphuric  acid  is  quite  commonly  employed  for 
this  purpose. 

Sauces,  such  as  Worcestershire,  Tabasco,  tomato  catsup,  etc., 
are  used  to  stimulate  a  flagging  appetite,  and  add  flavour  to  soups, 
broths,  etc.  Taken  in  great  moderation,  they  are  not  injurious,  and 
in  cases  of  alcoholism  they  are  sometimes  useful  by  inducing  the 
patient  to  take  more  food  and  less  liquor. 

For  invalids,  for  whom  strong  sauces  of  this  kind  should  always 
be  forbidden,  a  very  good  substitute  may  be  made  for  use  with 
broiled  fish,  etc.,  as  suggested  by  Chambers,  by  boiling  a  few  plain 
aromatic  herbs,  like  parsley  or  mint,  in  a  little  water,  and  adding 
pepper  and  salt. 

Horseradish  is  a  condiment  which  excites  the  flow  of  saliva  and 
gastric  juice  when  eaten  early  in  the  course  of  a  meal  with  meat 
or  raw  oysters,  or  otherwise. 


PART   III. 

COOKING. 

FOOD   PREPARATION   AND   PRESERVATION. 

THE   QUANTITY   OF  FOOD   REQUIRED. 


COOKING. 


The  Object  of  cooking  Food. — While  man  is  so  constituted 
that  it  is  possible  for  him  to  live  upon  raw  food  for  a  considerable 
length  of  time,  it  is  apparently  designed  by  Nature  that  a  large  por- 
tion of  his  food  should  be  cooked,  for  there  are  no  savage  races 
known  who  do  not  practise  the  art  of  cooking,  in  however  elemen- 
tary a  fashion,  and  progress  in  the  scale  of  development  and  civilisa- 
tion is  uniformly  accompanied  by  advance  in  the  art  of  cooking. 
Prehistoric  man  may  have  lived  wholly  on  raw  food,  berries,  fruits, 
shellfish,  etc.,  but  this  diet  is  not  suited  for  most  tribes  of  man  to- 
day, although  the  northern  Eskimo  still  prefers  to  eat  his  meat  raw 
and  frozen. 

It  is  owing  to  the  practice  of  cookery  that  the  dietary  of  civil- 
ised man  has  been  so  much  enlarged,  and  that  it  covers  a  wider 
range  of  materials  than  that  which  serves  for  the  nourishment  of  the 
lower  animals.  There  are  many  articles  of  diet  in  common  use,  and 
many  others  which  may  be  employed  as  food  in  an  emergency, 
which  are  not  only  unpalatable  but  are  wholly  indigestible  in  the 
raw  state,  but  which  are  rendered  nutritious  by  cooking,  and  it  is 
far  less  difficult  to  modify  the  mechanical  preparation  of  foods  than 
the  secretions  which  digest  them. 

Generally  speaking,  foods,  excepting  fruits,  having  organised 
structure  require  cooking. 

Of  the  different  varieties  of  food,  that  which  is  derived  from  ani- 
mals as  a  rule  requires  cooking  more  than  vegetable  food.  It  is  well 
known  that  some  vegetables  and  most  fruits  are  eaten  raw  by  pref- 
erence without  palling  upon  the  appetite,  but  raw  meat  of  almost 
any  kind  soon  becomes  wearisome,  and  if  consumed  exclusively  may 
even  excite  disgust.  Raw  milk,  eggs,  and  bivalves  are  an  exception 
to  this  statement.  The  process  of  cooking  food  accomplishes  in  gen- 
eral the  following  purposes : 

238 


COOKING. 


239 


I.  Cooking  develops  certain  flavours  in  the  food,  in  meat  particu- 
larly, which  are  agreeable  to  the  palate,  and  thereby  enables  man  to 
secure  variety  in  taste,  which  is  so  important  a  stimulus  to  the  ap- 
petite. 

II.  Most  food  is  altered  in  consistence  and  made  softer  by  cook- 
ing, although  this  is  not  always  the  case  (eggs,  for  example,  become 
harder  when  boiled).  The  food  is  therefore  easier  masticated  and 
mixed  with  the  various  digestive  fluids.  It  may  be  observed  that 
the  mere  question  of  solidity  of  food  does  not  necessarily  imply 
greater  toughness — in  fact,  the  albuminous  ingredients  of  meat  are 
coagulated  and  made  actually  more  solid  by  cooking,  but  at  the 
same  time  they  become  much  less  tough  or  are  more  friable,  in 
which  condition  they  are  more  easily  ground,  torn,  and  separated 
by  the  teeth. 

III.  The  chemical  changes  produced  in  food  by  cooking  seem  in 
some  instances  to  favour  the  action  of  the  digestive  juices  upon  the 
food.  This  is  particularly  true  of  some  of  the  forms  of  starch  and 
of  many  meats. 

Comparatively  little  attention  has  been  paid  to  the  chemical  alter- 
ations produced  in  food  by  the  various  processes  of  cooking.  Analy- 
ses of  food  are  usually  conducted  upon  the  raw  materials,  and  the 
important  alterations  which  are  occasioned  by  heat  in  various  de- 
grees are  still  imperfectly  understood  by  most  persons. 

IV.  By  cooking,  many  varieties  of  parasites  and  germs  which 
may  be  contained  in  the  food  are  destroyed,  and  bad  food  which 
might  otherwise  be  highly  poisonous  or  injurious  is  made  perfectly 
harmless. 

V.  The  temperature  of  food  which  is  sometimes  eaten  hot  may 
in  some  cases  favour  the  digestive  processes,  although  the  impor- 
tance of  this  consideration  is  apt  to  be  exaggerated. 

VI.  The  appearance  of  the  food  may  be  improved,  and  it  becomes 
more  appetising  on  this  account. 

Varieties  of  Cooking. — The  several  processes  of  cooking  which 
are  in  common  use  are  as  follows:  i.  Boiling,  2.  Stewing.  3.  Roast- 
ing. 4.  Grilling,  or  broiling.  5.  Frying.  6.  Braising.  7.  Baking. 
8.  Steaming. 

There  is  undoubted  advantage  in  varying  the  different  methods 
of  cooking  as  well  as  of  flavouring  the  food  from  time  to  time.  Mo- 
notony of  diet  and  of  flavours  lessens  the  appetite  and  fails  to  stimu- 
late the  digestive  organs  into  activity.  When  a  reasonable  variety  of 
food  cannot  be  obtained,  variety  in  cookery  may  be  made  to  replace 
its  advantages  to  a  great  extent.  Every  one  is  familiar  with  the 
effect  on  the  appetite  of  an  occasional  change  of  cooks  or  of  a  meal 
served  in  unwonted  surroundings. 

It  is  not  within  the  scope  of  this  work  to  discuss  the  details  of 
18 


240  FOOD   PREPARATION   AND   PRESERVATION. 

cooking  for  the  sick.  Miss  Nightingale  wrote  that  "  a  good  sick- 
cook  will  save  the  digestion  half  its  work,"  and  invalid  cookery 
should  form  the  basis  of  every  trained  nurse's  education.  It  is  im- 
possible here  to  do  more  than  explain  the  theory  of  the  chief  meth- 
ods of  cooking  and  suggest  occasionally  their  influence  upon  diges-' 
tion.  As  a  rule,  twice-cooked  meats  are  undesirable  for  invalids. 
They  are  apt  to  be  drier  and  less  nutritious  and  digestible  than  when 
fresh.  In  meat  "  hash,"  for  example,  the  meat  fibre  is  too  much 
hardened.  Such  preparations  are  often  made  too  greasy  by  recook- 
ing  for  delicate  stomachs.  The  same  statement  applies  to  canned 
meats  when  warmed  over,  for  they  have  been  already  cooked  once 
in  the  tin. 

It  is  undesirable  to  combine  foods  which  require  different  periods 
for  their  thorough  cooking.  For  example,  soup  needs  less  boiling 
than  the  vegetables  added  to  it,  and  they  should  be  partially  cooked 
alone  beforehand,  or  they  will  be  underdone. 

The  necessary  heat  for  cooking  is  obtainable  in  many  ways — 
from  coal,  wood,  gas,  oil,  steam,  and  even  electricity — and  these  dif- 
ferent methods  each  possess  advantages  for  particular  foods. 

Cooking,  as  a  rule,  at  a  prolonged  low  temperature  is  more  eco- 
nomical in  its  results  upon  food  than  a  much  shorter  application  of 
high  heat,  and  this  is  the  theory  of  the  famous  Count  Rumford 
kitchen. 

I.  Boiling;. — The  primitive  method  of  boiling  water  consisted  in 
heating  the  water  in  a  hollow  dug  in  the  ground  by  plunging  in  hot 
stones  taken  out  of  the  fire.  Later,  as  the  arts  of  pottery  making 
and  metal  working  became  known,  utensils  were  employed. 

In  some  excellent  remarks  by  Williams  on  the  subject  of  so-called 
boiled  food,  he  points  out  that  the  expression  "  boiled  "  beef,  or  eggs. 
or  potatoes,  implying  that  the  food  has  been  boiled  in  the  same 
manner  in  which  the  water  is  boiled,  is  an  absurdity.  The  food  is 
merely  heated  by  immersion  in  baLLkig  water,  and  even  such  water 
as  is  contained  in  the  meat  or  potato  is  not  itself  boiled  in  the 
process,  for,  he  says,  "  its  boiling  point  is  higher  than  that  of  the 
surrounding  water,  owing  to  the  salts  it  holds  in  solution.  Thus,  as 
a  matter  of  chemical  form  the  boiled  leg  of  mutton  is  one  that  has 
been  cooked  but  not  boiled,  while  the  roasted  leg  of  mutton  is  one 
that  has  been  partially  boiled.  Much  of  the  constituent  water  of  flesh 
is  boiled  out  and  fairly  driven  away  as  vapour  during  roasting  or 
baking,  and  the  fat  on  its  surface  is  also  more  or  less  dissociated 
into  its  chemical  elements,  carbon  and  water,  as  shown  by  the  brown- 
ing due  to  the  separated  carbon." 

It  is  a  scientific  fact  which  is  not  appreciated  by  many  persons 
that  when  water  has  once  reached  the  boiling  point,  its  temperature 
cannot  be  further  elevated  until  it  is  all  converted  into  steam,  for  all 


COOKING. 


241 


the  additional  heat  which  is  required  above  that  needed  to  warm  the 
water  and  drive  off  the  air-bubbles  in  the  process  of  ebullition  is  ex- 
pended in  vapourising  the  water  into  steam.  Consequently,  however 
hot  the  fire,  or  however  prolonged  the  cooking,  the  temperature  of 
the  food  suspended  in  boiling  water  cannot  be  increased  above  that 
of  the  water  itself;  and,  in  fact,  the  temperature  of  the  interior  of 
large  masses  of  food,  like  potatoes  or  meat,  is  by  no  means  as  great 
as  that  of  the  surrounding  water.  For  this  reason,  piling  fuel  upon 
the  fire  when  water  has  once  reached  the  boiling  point  will  have  no 
further  effect  than  that  of  accelerating  the  rate  of  ebullition,  without 
actually  raising  the  temperature  of  the  water  or  any  food  immersed 
in  it. 

Five  and  a  half  times  as  much  heat  is  required  to  convert  water 
at  the  boiling  point  into  steam  as  that  which  is  needed  to  raise  water 
from  the  freezing  to  the  boiling  point.  Count  Rumford  over  ninety 
years  ago  remarked  that,  while  the  boiling  temperature  of  water 
varies  considerably  at  different  levels,  meat  or  eggs  are  just  as  thor- 
oughly cooked  at  an  elevation  in  which  the  water  boils  at  209.5°  ^s 
they  are  at  the  sea  level,  where  the  boiling  temperature  is  212°  F. 

There  is  practically  no  distinction  to  be  made  between  "simmer- 
ing "and  boiling  as  a  process  of  cooking.  The  violent  boiling  of 
some  foods  tends  to  soften  them  somewhat  on  account  of  the  effect 
of  the  commotion-produced  in  the  water  by  the  rising  bubbles  which 
cause  currents  to  form  that  carry  particles  of  suspended  food  with 
them  and  triturate  them. 

The  operation  of  boiling  if  continued  for  an  hour  or  more  gradu- 
ally converts  the  connective  tissue  of  meat  fibre  into  gelatin,  which 
is  partially  dissolved  in  water,  and  the  heat  of  the  boiling  water 
usually  melts  a  little  of  the  fat,  which,  being  unable  to  mix  with  the 
water,  forms  a  scum  upon  the  surface.  A  small  proportion  of  the 
juices  of  meat  usually  osmoses  or  soaks  out  into  the  surrounding 
water,  and  the  aqueous  solution  thus  formed  is  called  broth  or  bou- 
illon. The  richness  of  the  broth  will  depend  principally  upon  the 
method  of  conducting  the  boiling  process.  When  it  is  desired  to 
have  the  broth  as  nutritious  as  possible  the  meat  must  be  finely 
minced  and  put  into  cold  water,  which  is  gradually  warmed  but  not 
actually  brought  to  the  boiling  point.  By  this  process  the  juices  of 
the  meat  are  slightly  dissolved  out  into  the  warm  water,  and  there- 
after, if  the  temperature  is  not  carried  above  160°  F.,  coagulation  of 
the  albumin  in  the  muscle  fibres  does  not  occur,  and  more  and  more 
of  their  constituents  are  dissolved  out  into  the  surrounding  water — 
but  this  is  not  true  boiling.  In  this  manner  the  natural  flavour  is 
very  much  better  preserved ;  in  fact,  the  common  extracts  of  meat  are 
made  by  soaking  finely  chopped  meat  in  cold  water  and  subsequently 
evaporating  the  water  from  the  ingredients  which  are  found  in  it. 


242        FOOD  PREPARATION  AND  PRESERVATION. 

On  the  other  hand,  when  broth  is  not  wanted  for  nutriment  it  is 
desirable  to  prevent  the  solution  of  the  juices  in  the  water  as  much 
as  possible,  and  this  is  accomplished  by  immersing  the  meat  suddenly 
into  water  actually  boiling,  where  it  should  be  left  for  five  minutes,^^ 
by  which  time  the  outer  layer  of  the  mass  will  be  hardened  by  coag- 
ulation and  will  have  a  firm  coating  which  is  not  permeated  by  the 
juices  within.  When  meat  is  cooked  in  this  manner  the  broth  is 
scarcely  of  any  food  value,  but  the  meat  is  much  more  palatable. 
After  the  boiling  temperature  of  the  water  has  been  maintained  for 
five  minutes  the  further  cooking  should  be  continued  at  a  lower  tem- 
perature of,  say,  165°  to  170°  F.  If  the  heat  is  less  than  this,  the 
interior  of  the  joint  or  other  piece  of  meat  is  imperfectly  cooked 
and  its  albumin  is  insufficiently  coagulated,  so  that  it  has  a  raw 
appearance.  If  the  actual  boiling  point  is  long  maintained,  the 
albumin  is  too  firmly  coagulated,  and  the  meat  becomes  tough 
and  stringy.  The  latter  error  in  boiling  is  very  commonly  per- 
petrated by  cooks,  and  it  must  be  observed  that  the  coagulation 
point  of  different  forms  of  albumin  varies  considerably,  ranging  from 
below  90°  to  above  165°  F.,  and  since  many  varieties  of  albumin  oc- 
cur in  the  different  kinds  of  animal  food  which  are  in  common  use, 
it  will  be  found  that  they  are  not  all  equally  well  cooked  by  exactly 
the  same  temperature.  It  is  important  that  the  coagulation  temper- 
ature of  a  given  albumin  should  not  be  greatly  exceeded  or  long 
maintained  if  the  food  is  to  remain  tender  and  digestible.  Parkes 
says  that  ammonium  sulphite  is  liberated  by  continued  boiling,  and 
an  acid  resembling  acetic  acid. 

When  meat  is  plunged  into  boiling  water  so  that  the  external  lay- 
ers are  solidified  some  of  the  water  which  they  contain  is  squeezed 
out  into  the  surrounding  fluid,  and  an  actual  loss  of  weight  in  the 
meat  occurs  which  may  reach  as  high  as  30  per  cent. 

The  addition  of  salt  to  water  in  boiling  fish  or  meat  is  described 
by  Williams  as  having  a  threefold  action  :  (i)  It  directly  acts  on  su- 
perficial albumin  with  coagulated  effect ;  (2)  it  slightly  raises  the 
boiling  point  of  the  water  ;  (3)  by  increasing  the  density  of  the  water, 
the  exosmosis  or  oozing  out  of  the  juices  is  less  active,  and  hence  the 
flavour  is  better  retained. 

When  very  salt  meat  is  to  be  cooked,  if  steeped  too  long  in  boil- 
ing water  its  nutritive  properties  are  impaired,  the  muscle  sarcolem- 
ma  becomes  too  hard,  and  the  meat  tasteless  and  tough.  In  such 
cases  it  may  be  well  to  boil  meat  less  completely,  and  finish  the 
cooking  by  some  other  method,  such  as  frying. 

2.  Stewing. — Stewing  differs  from  boiling  in  the  fact  that  the 
juices  of  the  meat  or  vegetables  are  dissolved  in  the  heated  water, 
whereas  in  boiling,  the  juices  are  kept  from  passing  out  into  the 
water  by  the  coagulation  of  the  external  surface  of  the  food  mass 


COOKING. 


243 


produced  by  immersing  it  suddenly  into  boiling  water.  The  proper 
temperature  for  stewing  is  between  135°  and  160°  F.  In  thick  stews 
the  juices  dissolved  in  the  water  are  eaten  together  with  the  cooked 
food,  but  in  some  instances,  as  in  the  making  of  beef  tea  and  some 
kinds  of  soups,  the  aqueous  solution  only  is  used.  Obviously,  the 
more  the  food  is  subdivided  the  greater  the  surface  exposed  to  the 
solvent  action  of  the  water,  and  hence  the  object  of  mincing  meat 
thoroughly  which  is  to  be  used  in  the  preparation  of  beef  tea.  If 
such  minced  meat  has  been  soaked  for  a  long  time  in  cold  water,  a 
part  of  the  albumin  and  the  extractive  materials  are  obtained  in 
solution,  but  the  meat  which  is  left  is  colourless,  tasteless,  and  un- 
palatable ;  in  fact,  animals  fed  upon  it  soon  deteriorate  in  strength. 

The  manner  in  which  stewing  differs  from  other  processes  of 
cooking  is  well  described  by  Williams,  who  says :  "  Instead  of  the 
meat  itself  surrounding  and  enveloping  the  juices,  as  it  should  when 
boiled,  roasted,  grilled,  or  fried,  we  demand  in  a  stew  that  the  juices 
shall  surround  or  envelop  the  meat."  And  more  or  less  water  enters 
the  substance  of  the  meat  to  replace  the  juices  which  have  passed 
out  by  osmosis  and  diffusion  into  the  surrounding  fluid.  After  meat 
has  been  stewed  for  some  time  a  scum  containing  a  little  coagulated 
albumin  and  more  or  less  fat  is  usually  seen  floating  upon  the  sur- 
face. This  is  usually  removed  in  the  preparation  of  beef  tea  for 
invalids  in  order  to  make  it  more  palatable  and  more  agreeable  to 
the  eye,  but  its  removal  is  at  the  expense  of  considerable  nutritious 
material.  In  the  preparation  of  extracts  of  meat,  such  as  Liebig's 
Extractum  Carnis,  the  scum  is  removed  before  the  solution  is  con- 
centrated by  evaporation. 

Stews  which  are  simply  made  in  the  manner  described  above,  and 
which  consist  largely  of  meat  and  plain  sliced  vegetables,  are  fairly 
digestible  ;  but  if  other  materials  or  rich  sauces  are  added  to  them, 
this  is  not  the  case,  and  if  saturated  with  fat,  they  are  quite  unfit 
for  invalids.  As  both  the  solid  substance  of  the*  meat  and  vegetables 
and  the  fluid  materials  which  have  been  extracted  from  them  are 
eaten  together  in  the  stew,  this  is  an  economical  form  of  preparing 
food.     Nothing  is  lost  by  evaporation,  and  nothing  is  thrown  away. 

3.  Roasting.  4.  Grilling. — The  processes  of  roasting  and  grill- 
ing or  broiling,  when  performed  over  a  very  hot  fire,  result  in  cooking 
the  meat  in  a  manner  which  is  in  some  respects  analogous  to  stew- 
ing: in  fact,  the  interior  portions  of  the  meat  are  stewed  in  their 
own  juices  instead  of  in  water  (Williams).  A  coating  of  coagulated 
albumin  forms  upon  the  outer  surface  of  the  meat,  while  the  albu- 
minous material  or  myosin  of  the  interior  is  gradually  warmed  and 
more  slowly  coagulated.  The  outer  coating  prevents  the  evapora- 
tion of  the  juices  of  the  meat  which,  together  with  the  extractive 
materials,  are  retained,  and  add  flavour  to  it.     Roasted  and  broiled 


244 


FOOD   PREPARATION   AND    PRESERVATION. 


meat  therefore  have  a  decided  advantage  in  flavour  as  well  as  in 
nutritive  value  over  meat  which  has  been  boiled  for  a  long  time, 
although  the  latter  may  be  tender  and  easily  digested. 

Roasting  and  broiling  are  the  most  universal  methods  of  cooking. 
For  them  the  savage  or  the  hunter  requires  no  utensils,  but  boiling" 
implies  the  aid  of  the  potter  or  worker  in  metals.  The  Polynesian 
cooks  his  meat  by  roasting  it  on  a  hot  stone,  and  sprinkles  it  with 
sea  water  to  obtain  the  salt.  The  primitive  hunter  incases  his  meat 
or  fowl,  skin  and  all,  in  damp  clay  and  roasts  it  in  hot  coals.  The 
Australian  savage,  the  lowest  type  of  man,  does,  all  his  cooking  by 
roasting. 

In  roasting,  the  high  temperature  which  is  applied  suddenly  to 
the  meat  produces  a  firmer  coagulation  of  its  outer  layers  than 
occurs  with  boiling.  Owing  to  this  fact,  the  natural  juices  of  the 
meat  are  almost  completely  retained,  and,  as  in  boiling,  the  heat 
should  be  strong  when  first  applied,  but  it  may  subsequently  be 
reduced  to  prevent  charring  of  the  surface.  This  may  be  accom- 
plished by  removing  the  meat  farther  away  from  the  fire. 

The  process  of  roasting  and  grilling  is  conducted  mainly  by 
radiant  heat,  although  there  is  slight  convection  through  the  air. 
The  main  object  of  an  oven  is  to  prevent  burning  by  uneven  cooking. 

The  principle  of  a  proper  roasting  oven  is  formulated  by  Williams, 
who  says  "the  meat  should  be  cooked  by  the  action  of  radiant  heat 
projected  towards  it  from  all  sides  while  it  is  immersed  in  an  atmos- 
phere nearly  saturated  with  its  own  vapour,"  and  the  heat  applied 
after  reaching  a  maximum  is  kept  uniform  throughout  the  process. 

In  boiling  or  stewing,  the  heat  is  applied  to  the  meat  by  convec- 
tion through  water,  and  this  is  an  important  discrimination  because 
the  air  which  surrounds  the  roasting  meat  is  constantly  removing 
the  water  which  tends  to  evaporate  upon  its  surface,  and  therefore 
to  dry  the  external  surface  of  the  meat.  From  20  to  24  per  cent  of 
water  is  lost  in  this  manner,  and  the  meat  therefore  weighs  less. 
The  evaporation  of  this  water,  which  continually  passes  from  the 
interior  of  the  meat  towards  the  outer  surface,  produces  a  loss  of 
heat  in  the  meat  itself  which  keeps  the  interior  from  becoming  over- 
heated. If  the  roasting  or  broiling  is  long  continued,  the  water 
gradually  passes  out  more  and  more  from  the  interior  of  the  mass, 
which  finally  becomes  dry  and  hardened  or  burned.  If  too  much  air 
surrounds  the  meat,  it  is  poorly  roasted,  dry,  and  leathery,  whereas 
if  the  heat  is  applied  more  directly  by  radiation  from  glowing  embers, 
the  sudden  hardening  of  the  outer  coating  of  the  meat,  even  though 
it  be  slightly  burned,  forms  a  barrier  against  the  evaporation  of 
water  from  the  interior. 

Broiling  or  grilling  is  a  means  of  quick  cooking  which  requires 
very  much  less  time  than  roasting  or  boiling,  because  intense  heat  is 


COOKING. 


245 


applied  to  comparatively  small  pieces  of  meat  or  fish.  It  is  really 
roasting  on  a  smaller  scale. 

The  object  of  broiling  as  well  as  of  quick  roasting  should  be  to 
raise  the  interior  of  the  mass  promptly  to  the  point  of  coagulation, 
or  about  180°  F.,  so  that  the  water  formed  shall  not  have  time  to 
wholly  evaporate.  It  is  consequently  advisable  for  the  meat  to  be 
cooked  as  near  the  glowing  surface  as  possible  to  increase  the  radia- 
tion and  diminish  the  convection  of  air  currents  (Williams).  It  is 
for  this  reason  that  steaks  and  chops  are  often  better  cooked  in 
restaurants,  where  specially  adapted  grills  are  used  which  bring  the 
meat  in  closer  relation  to  a  radiant  surface  of  glowing  coals  than  it 
is  usually  possible  in  domestic  cookery.  A  properly  cooked  steak 
or  chop  is  thickened  in  the  center,  but  if  badly  grilled  it  is  thin  and 
dry.  It  should  be  remembered  that  the  evaporation  depends  upon 
the  extent  of  the  surface  of  the  meat,  and  for  this  reason  thinly  cut 
steaks  or  chops  become  comparatively  dry  and  shrivelled  in  the 
centre.  This  principle  is  well  described  by  Williams,  who  says  that 
"  the  smaller  the  joint  to  be  roasted,  the  higher  the  temperature  to 
which  its  surface  should  be  exposed,"  excepting  where  very  large 
masses  of  meat  are  being  cooked,  when  it  becomes  necessary  to 
secure  time  for  the  heat  to  penetrate  into  the  interior  without  drying 
up  the  outside.  This  object  is  accomplished  by  constantly  basting 
the  surface  in  order  to  keep  it  wet  and  prevent  evaporation,  for 
while  the  surface  is  moistened,  its  temperature  will  not  rise  above 
the  boiling  point  of  the  liquid  which  is  used  to  moisten  it.  Pouring 
melted  fat  or  melted  butter  over  the  meat  checks  evaporation  almost 
completely,  and  in  the  case  of  large  joints  it  prevents  the  external 
portion  from  becoming  too  dry  and  indigestible  before  the  albumin 
of  the  interior  has  been  coagulated.  Small  lean  joints  of  meat  re- 
quire more  frequent  basting  with  fat. 

The  roasting  of  any  meat,  however,  cannot  be  accomplished 
without  the  effusion  of  some  of  the  meat  juice  and  the  melting  of  a 
portion  of  the  more  superficial  fat  and  of  gelatin.  These  substances 
together  constitute  the  meat  gravy,  which  is  itself  quite  nutritious 
and  which  is' advantageously  used  for  basting  the  meat  to  prevent 
drying,  as  well  as  to  distribute  the  heat  more  uniformly  over  the 
surface.  In  overroasted  or  "  burned  "  meat  the  external  layers  be- 
come scorched  or  charred,  and  this  is  due  chiefly  to  the  carbonising 
of  the  fat.  Before  the  fat  has  become  fully  burned,  certain  volatile 
fatty  acids  are  liberated  which  have  a  very  disagreeable  odour,  and 
various  products  are  developed  which  are  not  only  of  no  value  for 
nutrition,  but  which  may  be  positively  irritating  to  the  alimentary 
canal.  According  to  Yeo,  for  beef,  mutton,  and  game,  a  tempera- 
ture of  130°  F.  is  sufficient  for  proper  cooking,  and  the  meat  is 
"  tare  "  or  "  underdone,"  retaining  a  good  deal  of  its  reddish  colour ; 


246  FOOD   PREPARATION   AND   PRESERVATION. 

but  veal  and  poultry  should  be  cooked  at  a  higher  temperature — at 
from  158°  to  160°  F.  These  temperatures  are  lower  than  those 
often  used,  and  apply  rather  to.  the  degree  of  heat  which  is  to  be 
maintained  after  the  meat  is  first  placed  in  position  for  roasting, 
when,  as  previously  stated,  the  temperature  may  be  much  higher. 

Game  or  meat  which  is  "  high  "  or  somewhat  tainted  is  extremely 
repulsive  if  cooked  by  boiling  or  stewing,  when  it  disintegrates  more 
or  less  and  the  elements  of  decomposition  pass  into  and  flavour  the 
whole  mass.  Such  meat,  however,  is  sometimes  palatable,  and  is 
not  necessarily  unwholesome  if  cooked  by  roasting,  when  the  ex- 
ternal layers  which  have  first  commenced  to  decompose  are  thor- 
oughly browned  and  thereby  disinfected.  Some  persons  prefer  that 
a  leg  of  mutton  should  be  hung  until  it  becomes  slightly  odorous 
before  it  is  roasted,  but  it  must  be  fresh  for  boiling. 

5.  Frying. — Frying  is  a  process  of  cooking  by  which  the  heat  is 
transmitted  by  the  contact  of  the  food  with  melted  fat,  butter,  or  oil, 
and  not  by  radiation,  as  in  the  case  of  broiling  or  roasting.  As  ex- 
plained by  Williams,  the  fat  does  not  necessarily  boil,  for  the  food, 
as  well  as  the  fatty  material  itself,  may  contain  a  considerable  pro- 
portion of  water  which,  by  being  suddenly  vaporised,  produces  the 
familiar  spluttering  which  accompanies  the  process  of  frying. 

The  boiling  point  of  fats  is  very  much  above  that  of  water,  and 
the  vaporisation  of  the  former  is  complete  at  212°  F.  Between  300° 
and  500°  F.  may  be  required  to  vaporise  the  so-called  volatile  oils, 
but  fats  and  oils  used  in  cooking  do  not  apply  to  this  class,  and 
when  heated  above  400°  F.  they  turn  dark  brown  or  black  and  emit  a 
disagreeable  odour  and  smoke,  leaving  a  non-volatile  carbon  residue. 

The  process  of  frying  bears  somewhat  the  same  relation  to  boil- 
ing that  the  broiling  of  meat  does,  in  that  the  heat  employed  is 
considerably  greater.  It  is  suddenly  applied,  and  as  a  result  the 
external  surface  of  the  food  mass  is  coagulated  and  hardened  before 
the  juices  in  the  interior  have  time  to  escape.  For  this  reason,  deli- 
cate fish,  like  the  trout,  is  much  more  highly  flavoured  and  palatable 
when  fried  than  boiled.  More  or  less  butyric  acid  is  developed  from 
fat  in  frying. 

The  popular  idea  in  regard  to  frying  is  that  the  fat  used,  whether 
butter,  lard,  or  drippings,  is  simply  for  the  purpose  of  preventing 
food  from  adhering  to  the  frying  pan,  but,  from  the  explanation  of 
the  process  quoted  above,  it  is  seen  that  this  is  not  the  case,  and  the 
best  frying  is  done  by  immersing  the  food  completely  in  a  bath  of 
fat  or  oil.  Even  olive  or  sperm  oil  may  be  used  for  this  purpose, 
and  the  fish  or  other  food  is  lowered  in  an  open  wire  basket  or  net- 
ting into  a  deep  pan  which  contains  the  fat,  in  which  it  is  completely 
submerged.  There  is  no  danger  of  the  fat  soaking  into  the  food  if 
it  is  sufficiently  hot  and  if  the  process  is  not  too  long  continued,  for, 


COOKING. 


247 


as  stated  by  Williams,  "the  water  amid  the  fibres  of  the  fish  is  boil- 
ing and  driving  out  steam  so  rapidly  that  no  fat  can  enter  if  the 
heat  is  well  maintained  to  the  last  moment."  Fritters  cooked  in 
this  way  are  light  and  puffy  from  the  sudden  expansion  of  the  water 
which  they  contain  into  large  bubbles  of  steam,  and  are  consequently 
decidedly  more  digestible.     Bacon  fries  in  its  own  fat. 

Frying  is  less  perfectly  understood  by  cooks  than  almost  any 
other  method  of  preparing  meat,  and  the  process  as  usually  carried 
out  results  in  very  unwholesome  products.  The  pans  used  are  too 
shallow,  and  the  food  and  fat  are  apt  to  be  scorched. 

When  the  meat  or  other  material  is  dipped  into  hot  melted  oil  or 
fat,  more  or  less  of  it  clings  to  the  surface  of  the  food,  and  for  this 
reason  may  render  it  unfit  for  persons  with  feeble  digestive  powers. 
In  the  case  of  fish  cooked  in  this  manner  with  their  scales,  the  fat 
which  adheres  to  them  may  be  easily  removed  when  eaten,  and  the 
meat  within  will  be  found  to  be  quite  digestible;  but  meat,  such  as 
steak,  cooked  by  frying  is  notoriously  indigestible.  Salt  meat  may 
be  cooked  first  by  boiling  before  frying,  as  in  the  case  of  hams, 
although  the  latter  may  be  subsequently  roasted  instead  of  fried. 
Such  meats  always  require  prolonged  cooking.  According  to  Yeo, 
the  addition  of  a  little  vinegar  tends  to  make  them  more  tender. 

6.  Braising^. — Braising  is  a  method  of  cooking  meat  by  which  it 
is  immersed  in  a  solution  of  vegetable  and  animal  juices  called 
"  braise,"  contained  in  a  covered  vessel,  in  which  it  is  exposed  to  a 
strong  but  not  boiling  temperature.  It  is  of  value  especially  for 
cooking  tough  meat  of  any  sort  or  meat  which  is  too  fresh  or  young. 
The  cover  of  the  kettle  is  so  arranged  as  to  prevent  evaporation 
from  occurring  to  any  extent;  the  meat  becomes  permeated  in  the 
long  cooking  with  the  juices  of  fresh  vegetables  and  herbs,  and  is 
kept  from  drying. 

Towards  the  end  of  the  process  cooking-sherry  or  spices  may  be 
added,  such  as  cloves  or  mace,  or  thin  slices  of  bacon.  The  amount 
of  fluid  used  should  be  but  barely  sufficient  to  cover  the  meat,  and 
in  this  way  the  surrounding  broth  is  kept  very  concentrated.  Some- 
times the  meat  which  is  braised  is  partially  roasted. 

7.  Baking. — Baked  meat  is  prepared  by  cooking  in  a  confined 
space,  which  prevents  the  volatile  products  which  are  driven  off  in 
roasting  from  escaping,  and  consequently  the  meat  has  a  some- 
what stronger  and  less  delicate  flavour  than  when  roasted ;  it  is  also 
richer,  and  is  apt  to  disagree  with  dyspeptics.  It  becomes  saturated 
with  empyreumatic  oils  unless  its  surface  is  protected  by  a  pie  crust, 
but  even  that  does  not  add  to  its  digestibility. 

The  baking  of  bread  is  described  on  page  121. 

8.  Steaming. — Cooking  by  steaming  is  a  method  but  little  used, 
and  is  mainly  applied  to  cereals,  puddings,  etc. 


248  FOOD   PREPARATION   ANB   PRESERVATION. 

Soups. — Meat  soups  are  made  by  continued  boiling,  which  con- 
verts the  connective  tissue  of  meat  fibres  into  gelatin,  which  is  grad- 
ually dissolved  into  the  water.  The  soup  thus  becomes  an  aqueous 
solution  of  gelatin,  with  some  of  the  extracts  of  the  meat  for  flavour- 
ing. Whatever  albumin  is  dissolved  and  what  little  fat  may  be 
melted  forms  a  scum  on  the  surface.  The  insoluble  albumin  becomes 
coagulated  and  floats  about  in  small  particles,  which  are  strained 
away  if  the  soup  is  to  be  clear,  but  this  process  makes  it  less  nutri- 
tious for  invalids.  If  a  really  rich  soup  or  nutritious  broth  is  to  be 
made  from  any  piece  of  meat,  so  much  of  the  latter  is  dissolved  into 
the  water  that  the  residue  is  tasteless,  tough,  and  so  indigestible  that 
it  is  practically  useless.  On  the  other  hand,  there  are  many  scraps 
of  meat  or  parts  which  are  unsightly  or  less  useful  for  food  from 
which  very  nutritious  broth  may  be  made,  and  the  inedible  bones 
are  utilised  in  the  same  manner. 

The  extent  to  which  soups  and  broths  may  be  made  nutritious 
depends  largely  upon  the  character  of  the  meat  used,  and  Parkes 
placed  meats  in  the  following  order  in  regard  to  the  nutritive  value 
of  their  broths,  commencing  with  the  strongest :  Chicken,  mutton, 
and  beef.  He  said  that  the  best  broth  made  from  beef  contains  150 
grains  of  nitrogenous  nutriment  to  the  pint  and  90  grains  of  salts, 
for  nearly  all  of  the  salts  of  the  beef,  chiefly  chlorides  and  phos- 
phates, dissolve  out  into  the  surrounding  water. 

When  a  few  drops  of  dilute  hydrochloric  acid  are  added  to  minced 
meat  immersed  in  water,  the  acid  converts  the  muscle  albumin  into 
syntonin,  which  is  soluble  in  cold  water,  and  after  soaking  in  it  for 
several  hours  a  moderately  nutritious  broth  can  be  obtained.  Such 
broth  may  be  heated  to  130°  F.  without  coagulation,  when  it  will  be 
found  to  contain  nearly  50  per  cent  of  the  meat  albumin  (Parkes). 
(See  Receipts  for  Beef  Tea,  page  769). 

Cooking  of  Fish. — Fish  may  be  cooked  by  boiling,  grilling, 
baking,  frying,  or  stewing.  Of  these  several  methods,  boiling  is 
decidedly  the  most  advantageous  for  persons  with  feeble  digestions, 
and  next  in  order  is  broiling.  When  fish  is  boiled  without  the 
addition  of  salt  to  the  water  it  is  apt  to  become  soft  and  disinte- 
grated, but  if  boiled  in  sea  water  or  artificially  salted  water  it  main- 
tains its  shape  and  flavour.  The  quantity  of  salt  present  regulates 
the  osmosis  of  the  juices  of  the  fish  into  the  water.  As  a  rule,  fish 
requires  much  less  time  than  meat  for  cooking. 

If  fried  fish  is  to  be  eaten  by  dyspeptics,  it  should  be  cooked 
whole,  and  the  skin  must  be  carefully  removed  subsequently.  It  is 
never  as  digestible  as  boiled  fish. 

Cooking  of  Vegetables. — The  object  of  cooking  vegetables,  as 
in  the  case  of  cooking  meat,  is  to  render  them  more  digestible,  to  give 
variety,  to  modify  their  flavour,  and  in  some  cases  to  preserve  them. 


FOOD  CONCENTRATION.— CONDENSED  FOOD. 


249 


Some  coarse  vegetables,  such  as  turnips,  carrots,  beats,  and  pota- 
toes, while  they  make  good  raw  food  for  animals,  are  unpalatable 
and  indigestible  for  man,  and  require  softening  and  alteration  by 
prolonged  boiling  in  soft  water  or  by  some  other  form  of  cooking. 
The  cooking  of  vegetables  macerates  the  cellular  fibres  or  walls  of 
the  cells  and  softens  their  contents,  rendering  the  vegetable  much 
more  easy  of  mastication,  while  the  effect  of  the  heat  and  moisture 
is  to  cause  swelling  and  rupture  of  the  starch  granules,  in  which 
condition  they  are  more  easily  and  promptly  acted  upon  by  the 
starch-digesting  ferments  contained  in  the  saliva  and  pancreatic 
juice. 

Many  vegetables  contain  proteid  or  albuminous  substances, 
besides  sugars,  gums,  and  starches.  The  albuminous  material  is 
coagulated  by  appropriate  temperature  and  the  other  matters  are 
more  or  less  soluble  in  water. 

Most  vegetables  contain  a  very  large  percentage  of  water  in 
their  natural  state,  but  in  most  of  the  cooking  processes  to  which 
they  are  subjected,  excepting  perhaps  in  baking  potatoes  and  the 
like,  water  is  always  added  in  considerable  quantity,  either  hot  or 
cold. 

FOOD  CONCENTRATION.-CONDENSED   FOOD. 

The  concentration  of  food  is  based  upon  the  fact  that  many 
foods  contain  a  large  percentage  of  free  water,  which  can  be  driven 
off  by  evaporation,  thereby  reducing  the  weight,  and  usually  the 
bulk  of  the  food  as  well.  Slight  further  condensation  may  be  ac- 
complished by  pressure  through  machinery  which  is  capable  of  ap- 
plying a  force  of  several  tons  to  the  square  inch. 

Drying.  Desiccation.  Extracts.— If  the  process  of  drying  is 
not  carried  beyond  a  partial  evaporation,  the  food  is  called  "  con- 
densed." It  may,  however,  be  continued  until  the  food  is  wholly 
dry,  in  which  case  the  substance  may  be  either  "  desiccated  "— i.  e., 
torn  into  shreds— or  pulverised.  Condensed  and  powdered  foods  may 
be  added  to  other  foods  in  order  to  thicken  them  or  add  to  their 
nutritive  power. 

The  nutritive  principles  of  foods  may  be  extracted  by  glycerin 
or  acid  solutions  and  other  materials,  and  the  resulting  extract  is 
condensed  by  evaporation  to  the  consistence  of  a  paste  or  powder. 
Beyond  this  it  is  not  possible  to  concentrate  foods  by  chemical 
process,  for  a  definite  bulk  of  food  must  be  daily  consumed  from 
which  to  derive  the  energy  for  the  body  and  the  substance  needed 
for  repair. 

Drying  is  conducted  either  in  the  heat  of  the  sun  or  by  artificial 
means.     The  class  of  dried  foods  embraces  the  various  forms  of 


250 


FOOD   PREPARATION   AND   PRESERVATION. 


dried  and  desiccated  meat  and  fish,  dried  milk,  dried  vegetables  and, 
fruits,  such  as  peas,  beans,  lentils,  corn,  okra,  apples,  peaches,  cocoa- 
nuts,  grapes  (raisins),  figs,  etc.  The  addition  of  sugar,  flour,  or  salt 
by  abstracting  moisture,  aids  the  drying  and  helps  to  prevent  decom- 
position (see  Food  Preservation  by  Drying,  page  253). 

Milk  may  be  dried  in  vacuo  and  preserved  by  itself  as  a  powder, 
or  mingled  with  other  materials,  such  as  malt  and  various  starchy 
foods.     Condensed  milk  has  been  already  described  (page  81). 

Eggs  may  also  be  successfully  dried ;  they  keep  well,  especially 
when  mixed  with  farinaceous  materials. 

Froissart  relates  how  the  King  of  France  in  the  invasion  of  Eng- 
land in  1386  had  the  yolks  of  eggs  packed  and  stored  in  barrels  to 
furnish  rations  for  the  troops.  Egg  albumen  dries  in  the  form  of 
thin  scales  which  may  be  indefinitely  preserved. 

Meat. — The  preservation  of  meat  and  fish  by  drying  is  probably 
the  oldest,  as  it  is  the  most  primitive,  method  in  use.  Meat  drying 
is  practised  extensively  among  savage  tribes  in  almost  all  parts  of 
the  world,  but  especially  where  purity  of  the  atmosphere  combined 
with  intense  heat  and  dryness  of  climate  will  cause  the  water  to 
evaporate  from  the  meat  so  rapidly  that  germs  do  not  have  time  to 
decompose  it.  For  this  purpose  only  lean  meat  can  be  used,  as  the 
fat  does  not  part  with  its  water  with  sufficient  readiness.  Dried 
meat  loses  much  in  weight,  becomes  hard  and  tough,  and  in  many 
cases  tasteless.  It  is  therefore  usually  indigestible,  and  requires 
prolonged  cooking  and  proper  seasoning.  When  prepared  in  this 
way,  the  drying  process  may  be  applied  very  thoroughly,  and  the 
food  is  more  easily  cooked  and  seasoned.  Dried  meat  may  be  pre- 
digested,  evaporated,  powdered,  and  made  into  a  paste  for  broths, 
or  used  to  re-enforce  various  food  preparations  for  invalids.  Pow- 
dered meat  is  sometimes  mixed  with  sugar  and  salt,  or  pulverised 
dried  cooked  vegetables,  bread,  etc.  Meat  extracts  have  been  de- 
scribed in  detail  on  pages  97  to  105. 

Pemmican  is  a  preparation  of  dried  powdered  meat,  which  has 
been  mentioned  on  page  178. 

Dried  vegetables  keep  even  better  than  dried  meats.  Tea  and 
coffee  are  good  examples  of  dried  vegetable  substances.  They  may 
be  extracted  and  then  concentrated  by  evaporation.  Potatoes  are 
concentrated  by  drying  to  less  than  one  third  of  their  original 
weight,  and  they  may  be  thus  preserved  in  slices  or  in  granular 
form.  Many  other  vegetables  are  prepared  by  drying,  and,  in  addi- 
tion, some  are  compressed,  as,  for  example,  cabbage,  cauliflower, 
carrots,  etc.  The  compression  still  further  excludes  air  and  mois- 
ture. As  a  rule,  dried  vegetables  are  only  serviceable  for  relieving 
monotony  of  diet  when  fresh  vegetables  cannot  be  obtained.  Desic- 
cated vegetables  have  been  used  with  some  success  in   the  United 


FOOD  CONCENTRATION.— CONDENSED  FOODS. 


251 


States  navy,  but  they  have  less  antiscorbutic  property  than  fresh 
foods. 

Bread  vs\7iy  be  preserved  for  a  long  time  by  drying,  but  it  usually 
becomes  tasteless,  and  is  useful  in  this  condition  only  in  emergencies, 
or  to  make  variety  in  the  rations  of  sea  biscuits,  hard-tack,  etc., 
which  are  furnished  to  soldiers  and  sailors  in  active  service. 

Captain  Woodruff,  Assistant  Surgeon,  U.  S.  Army,  writes  of  this 
subject :  "  The  Germans  have  been  the  first  to  take  advantage  of 
drying  and  compressing  processes  in  the  manufacture  of  a  dried, 
compressed  bread.  The  great  difficulty  in  the  use  of  bread  for  field 
use  consists  in  the  inability  to  supply  it  so  that  it  will  keep  a  long 
time  and  be  digestible.  Hard-tack  is  ruinous  to  many  soldiers,  as 
already  pointed  out.  If  baker's  bread  is  compressed,  it  sinks  into 
a  heavy  dough.  Only  strong  stomachs  can  digest  it,  and  it  is  far 
worse  than  the  wet,  soggy,  hot  breakfast  bread  with  which  we  culti- 
vate dyspepsia.  If  the  bread  is  merely  dried,  it  is  too  bulky  for 
transportation.  By  a  new  process,  which  probably  consists  in  dry- 
ing the  bread  and  at  the  same  time  compressing  it  by  improved 
machinery,  the  Germans  have  secured  a  variety  of  field  bread  which 
is  spoken  of  in  very  high  terms.  Small  bits  of  it  thrown  into  soup 
swell  up  like  a  dried  sponge  when  thrown  into  hot  water.  The  sol- 
diers are  said  to  be  very  fond  of  it,  and  as  far  as  known  it  is  entirely 
successful. 

"The  French  Department  of  Intendance  has  been  experimenting 
with  dried  bread,  which  is  said  to  be  superior  for  campaigning  pur- 
poses both  to  biscuit  and  ordinary  bread.  From  the  results  of  the 
experiment,  which  are  given  in  the  Revue  du  Service  de  I'lntendance 
Militaire,  it  appears  that  this  dried  bread  will  absorb  from  five  to  six 
times  its  own  weight  of  water,  milk,  tea,  coffee,  or  bouillon.  Biscuit 
absorbs  hardly  its  own  weight  of  liquid,  although  when  thoroughly 
dried  it  contains  only  about  10  per  cent  of  water,  whereas  the  bread 
contains  from  12  to  14  per  cent.  It  can  be  made  in  cubes  of  conven- 
ient form." 

Diet  of  Concentrated  Foods. 

There  are  many  complex  dried  foods  in  market  prepared  espe- 
cially for  invalid  diet,  and  supposed  to  possess  high  nutritive  value 
with  small  bulk.  As  compared  with  fresh  food,  their  lighter  weight 
and  greater  concentration  make  them  valuable  articles  for  tempo- 
rary invalid  diet,  but  they  cannot  be  said  to  possess  any  special 
advantage  over  freshly  made  broths,  scraped  beef,  etc.,  excepting  in 
those  cases  in  which  it  is  important  to  lessen  the  bulk  iind  increase 
the  strength  of  the  food. 

Attempts  have  from  time  to  time  been  made  in  the  German  army 


252 


FOOD   PREPARATION   AND   PRESERVATION. 


and  elsewhere  to  supply  healthy  men  with  a  daily  diet  of  concen- 
trated foods.  If  this  could  be  done,  it  would  be  of  great  economic 
advantage  for  troops  on  the  march,  explorers  in  unknown  countries, 
sailors  on  long  voyages,  and  for  use  in  many  ways,  but  after  a  few^ 
days  or  a  week  of  such  treatment  men  lose  in  weight  and  deteri- 
orate in  strength.  It  is  not  found  practical  to  give  food  for  any 
length  of  time  in  which  the  total  solid  ingredients  are  concentrated 
to  less  than  twenty-two  or  twenty-three  ounces  for  the  day's  ration, 
although  for  a  few  days  food  may  be  used  in  which  they  have  been 
reduced  to  ten  or  twelve  ounces  (Parkes).  Pea  meal  (page  146)  and 
pemmican  (page  178)  are  the  most  noted  rations  of  this  class,  to  which 
bacon,  hard-tack,  concentrated  meat  extracts,  coffee,  and  chocolate 
are  often  added. 

In  a  series  of  very  instructive  and  important  articles  upon  Mili- 
tary Food,  published  in  the  Journal  of  the  American  Cavalry  Asso- 
ciation, Captain  Woodruff  says:  "Concentration  only  means  the 
exclusion  of  the  indigestible  portions  and  part  of  the  water.  Thus 
the  garrison  ration  gives  to  each  man  about  five  pounds  of  food,  of 
which  only  four  pounds  are  eaten,  and  it  is  impossible  to  condense 
this  amount  so  that  it  will  be  much  less  than  three  pounds.  All  foods 
that  are  compressed  and  dried  still  contain  from  5  to  12  per  cent  of 
water.  The  German  soldier's  war  ration  is  equivalent  to  about  two 
pounds  of  water-free  food  in  the  above  sense.  This  is  not  enough  for 
American  soldiers  during  hard  work,  yet  it  is  possible  in  an  emer- 
gency to  give  the  soldier  fairly  good  nourishment  with  these  im- 
proved foods,  and  not  allow  the  weight  to  be  over  two  pounds, 
as  seen  in  the  following  table,  in  which  the  analyses  are  only  ap- 
proximate : 


GRAMMES. 

Calories. 

Articles. 

Protein. 

Fats. 

hjdttts.      S^'- 

Weights. 

3    cubes    dried    compressed 
bread,  J  pound  each 

3  packages  compressed  soup, 
6  ounces  each 

35 
100 

4 
150 

250 
200 

2 
28 

1,233 
2,625 

f  pound. 

3  tablets  compressed  tea  or 
coffee  ready  for  use,  possi- 
bly a  tablet  of  dried  fruit . 

Total 

135 

154 

450 

30 

3,858 

*  2  pounds. 

*  Gross  weight. 

"  The  composition  of  the  bread  is  assumed  to  be  the  same  as 
ordinary  flour,  and  the  tablets  of  soup  can  be  manufactured  of  the 
given  composition.  As  usually  made,  the  tablets  do  not  contain  so 
much  fat,  which  is  here  purposely  increased  in    order   to  give  the 


FOOD  CONCENTRATION.— CONDENSED  FOODS. 


253 


necessary  energy.     Even  with  this  increase  they  would  not  contain 
as  much  as  the  first  specimens  of  Erbswurst. 

"  For  purposes  of  detached  service  the  United  States  soldier  has 
been  supplied,  as  seen  in  the  following  table: 


Articles. 


I  pound  hard-tack.. . , 

f  pound  bacon 

Coffee,  sugar,  and  salt 

Total 


GRAMMES. 

Calories. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Salts. 

50 
27 

5 
236 

340 

2i 

19 

1,644 
2,310 

77 

241 

340 

30 

3.954 

Weights. 


1  pound. 

i       " 

i       "     . 

2  pounds.' 


Food  Preservation. 

The  different  methods  of  food  preservation  have  of  late  years  re- 
ceived much  attention,  for  it  is  owing  to  them  very  largely  that  it  is 
possible  to  maintain  large  armies  and  navies  in  action  and  to  permit 
of  the  aggregation  of  men  in  communities  away  from  all  immediate 
sources  of  food  supply. 

It  was  originally  believed  that  contact  with  air  wa.sj>er  se  the  cause 
of  the  decomposition  of  food,  but  it  is  now  known  that  the  great  num- 
ber of  germs  contained  in  even  comparatively  "pure  "  atmospheric 
air  are  the  agents  of  putrefaction  rather  than  the  air  itself,  but  the 
exclusion  of  the  one  implies  the  exclusion  of  the  other. 

The  different  methods  of  preserving  foods  are  therefore  all  de- 
pendent upon  the  principle  of  preventing  fermentative  changes  which 
are  liable  to  occur  when  germs,  derived  either  from  the  atmospheric 
air  or  contamination  with  unclean  substances,  come  in  contact  with 
foods  under  favourable  conditions  of  warmth  and  moisture.  The 
conditions  which  are  inimical  to  the  development  of  bacteria  are 
those  which  may  be  successfully  adopted  for  the  preservation  of 
food. 

.  Ferments  and  putrefactive  germs  require  for  their  activity  a  fair 
degree  of  moiature,  a  moderately  warm  temperature,  which  for  many 
putrefactive  germs  ranges  between  60°  and  100°  F.,  while  certain 
germs  must,  in  addition,  have  free  oxygen  derived  from  the  atmos- 
pheric air. 

The  principal  means  employed  for  preserving  food  are  included 
under  the  following  headings: 

I.  Drying.  II.  Smoking.  III.  Salting.  IV.  Freezing.  V.  Re- 
frigeration. VI,  Sterilisation.  VII.  Exclusion  of  Air — Canning. 
VIII.  Addition  of  Antiseptic  and  Preservative  Substances. 

I.  Drying. — Drying  in  the  sun  or  before  a  fire  is  probably  the 
oldest  of  methods  of  preserving  food.     At  present  it  is  used  mainly 


254 


FOOD  PREPARATION  AND  PRESERVATION. 


for  fruits  and  vegetables,  although  in  some  excessively  dry  and  clear 
atmospheres,  comparatively  free  from  putrefactive  bacteria,  meat 
also  may  be  preserved  in  this  way.  "  Jerked  "  meat  is  kept  by  cut- 
ting it  into  thin  slices  and  drying  in  the  sun  for  several  days.  Fa-_ 
miliar  instances  of  preservation  by  drying  are  found  in  raisins,  figs, 
dates,  prunes,  dried  apples,  peaches,  desiccated  cocoanut,  etc.  Some 
vegetables  are  also  preserved  in  this  manner,  such  as  Lima  beans, 
okra,  corn,  etc.  Others  are  cut  into  slices  and  then  dried,  but  the 
latter  are  apt  to  become  tough  and  tasteless.  Fish,  such  as  the  cod, 
is  desiccated  and  preserved  by  drying,  but  with  the  addition  of  salt. 
The  desiccated  meats  and  vegetables  which  are  used  for  making 
soups  have  the  advantages  of  portability  and  permanency.  They 
are  nutritious,  and  may  be  added  to  strong  beef  tea  to  increase  its 
flavour  and  make  it  more  palatable. 

This  subject  has  been  further  discussed  under  the  heading  Food 
Concentration  (page  249). 

II.  Smoking. — Smoking  is  the  preservation  of  meat  or  fish  by 
means  of  volatilised  creosote  and  other  substances  developed  from 
wood  or  peat  smoke,  which  have  an  antiseptic  action.  It  is  chiefly 
applied  to  beef,  tongue,  ham,  bacon,  and  fish.  The  meat  or  fish  is 
hung  in  a  confined  chamber  and  saturated  with  wood  smoke  for  a 
long  time,  so  that  it  absorbs  a  small  percentage  of  antiseptic  materi- 
als, the  fat  is  prevented  from  becoming  rancid  and  the  albumin  from 
putrefying.  The  smoking  is  commonly  employed  after  salting  and 
in  connection  with  drying.  Painting  the  surface  of  meat  with  a  solu- 
tion of  wood  creosote  in  vinegar  has  the  same  preservative  action. 

The  outer  surface  of  meat,  such  as  ham  or  bacon,  preserved  by 
smoking  becomes  considerably  drier  and  tougher  than  the  interior, 
but  the  latter  is  not  made  especially  tough  by  the  smoking  if  it  was 
originally  tender.  Well-smoked  bacon  cut  thin  and  thoroughly 
cooked  is  a  digestible  form  of  fatty  food  for  tubercular  patients, 
and  smoked  beef  may  sometimes  be  eaten  for  the  sake  of  variety  by 
patients  who  are  placed  upon  a  meat  diet.  The  digestibility  of  hams 
is  enhanced  by  the  smoking  process  to  which  they  are  subjected. 

The  process  of  smoking  is  applied  to  fish  upon  a  very  large  scale, 
and  their  digestibility  and  flavour  cannot  be  said  to  be  destroyed  by  it 
in  many  cases  ;  in  fact,  in  some  instances,  as  in  those  of  smoked  mack- 
erel, herring,  and  salmon,  while  the  flavour  is  very  different  from  that 
of  the  fresh  fish,  it  is  agreeable  to  many  persons,  and  these  articles 
aff'ord  an  important  and  appetising  variety  of  food. 

III.  Salting. — The  process  of  salting  is  a  primitive  but  still  de- 
sirable method  of  preserving  meat  and  fish.  Salted  meat  usually 
becomes  pale  from  the  action  of  the  salt  upon  the  haemoglobin  con- 
tained in  the  blood  vessels  of  the  muscle  fibre.  The  addition  of  a 
little  saltpetre  helps  to  preserve  the  original  reddish  colour  of  salted 


FOOD   CONCENTRATION.— CONDENSED   FOODS. 


255 


meat.     Salt  also  absorbs  moisture  from  the  food,  and  thus  dries  it 
while  preserving  it. 

Brine,  a  strong  solution  of  common  salt,  may  be  used  to  tempo- 
rarily preserve  meat  and  other  substances.  The  Chinese  have  long 
practised  the  art  of  preserving  fruits,  roots,  and  flowers  in  it.  Corned 
beef  is  made  by  soaking  the  meat  for  some  days  in  such  a  solution. 
The  brine  acts  upon  the  muscular  tissues  and  toughens  it.  Brine, 
concentrated  by  long-continued  use,  has  been  known  to  acquire 
poisonous  properties  from  changes  in  the  organic  matter  which  has 
passed  into  it  from  the  meat.  The  process  of  soaking  in  brine  causes 
much  of  the  extractives  and  natural  salts  of  the  meat  to  osmose  out 
from  it,  and  the  loss  of  organic  material  and  salts  occurring  in  this 
way  has  been  estimated  by  Liebig  and  Parkes  as  equal  to  fully  one 
third,  for  myosin  itself  is  soluble  in  strong  salt  solution.  For  these 
reasons  salted  meats,  such  as  corned  beef,  require  prolonged  cooking. 
Salt  meat  of  all  kinds  is  drier,  less  digestible,  and  slightly  less  nutri- 
tious than  fresh  meat. 

IV.  Freezing. — Food  may  be  kept  in  a  frozen  condition  almost 
indefinitely.  On  being  thawed,  it  must  be  cooked  immediately,  other- 
wise decomposition  is  apt  to  set  in  at  once,  and,  omitting  milk  and 
cream,  food  is  not  easily  eaten  in  an  actual  frozen  state,  excepting 
by  the  northern  Eskimos,  who  take  their  meat  in  that  form  by  pref- 
erence. 

Meat  and  fish  may  be  kept  for  many  days  frozen  in  blocks  of  ice 
without  losing  much  in  flavour,  but  vegetables  are  not  as  good  when 
cooked  after  freezing. 

In  1867  Dr.  Carl  von  Baer  reported  to  the  Royal  Society  of  Lon- 
don the  discovery  in  arctic  Siberia  of  the  body  of  a  frozen  mam- 
moth, the  meat  of  which  was  preserved.  As  this  animal  has  been 
extinct  since  the  days  of  prehistoric  man,  it  afforded  an  illustration 
of  the  marvellous  preservative  power  of  intense  cold.  Another  such 
animal  was  found,  in  1799,  being  eaten  by  wolves  in' Siberia. 

In-i86i  the  entire  bodies  of  three  Swiss  guides  were  found  in  a 
state  of  excellent  preservation  which  forty-one  years  before  had 
been  buried  by  an  avalanche  over  the  Glacier  de  Boissons.  With 
these  examples  of  the  influence  of  cold,  it  is  little  wonder  that  meat 
may  be  preserved  for  a  few  months  in  ice  and  yet  be  quite  fit  to 
eat. 

Meat  actually  frozen  should  be  cooked  as  soon  as  it  is  thawed, 
and  meat  thus  preserved  is  better  cooked  by  roasting  than  boiling, 
unless  it  has  been  imperfectly  thawed,  in  which  case  the  central  por- 
tion may  remain  frozen  after  the  external  layers  have  begun  to  cook, 
and  when  the  latter  are  thoroughly  roasted,  the  inside  may  still  be 
found  almost  raw.  Frozen  meat  loses  10  per  cent  of  its  nutritive 
value  in  cooking. 
10 


^ 


FOOD  PREPARATION  AND  PRESERVATION. 


V.  Refrigeration. — The  process  of  refrigeration  does  not  in- 
volve the  actual  freezing  of  meat  or  vegetables,  but  implies  their 
preservation  in  chambers  at  a  temperature  which  is  maintained  but 
a  few  degrees  above  the  freezing  point.  This  causes  less  alteration 
in  flavour  than  freezing.  The  cold  is  artificially  generated,  and" 
beef,  fish,  fruits,  and  vegetables  are  now  successfully  transported  for 
thousands  of  miles  in  refrigerator  cars  and  rooms  fitted  for  the 
purpose  on  steamboats. 

The  refrigerating  processes  applied  to  the  preservation  of  meat, 
etc.,  are  several.  In  most  of  them  the  actual  reduction  of  tempera- 
ture of  the  meat  is  maintained  by  cold  air  and  not  by  contact 
with  ice. 

One  method  consists  in  the  adaptation  of  the  principle  that  com- 
pressed air  on  expanding  derives  the  energy  for  its  expansion  from 
heat,  which  it  abstracts  from  all  surrounding  bodies.  The  liberation 
of  strongly  compressed  air,  therefore,  produces  intense  local  cold  in 
its  immediate  vicinity.  The  air  is  originally  compressed  by  a  force 
pump,  and  the  heat  which  is  developed  by  the  compression  is  re- 
moved by  a  circulating  stream  of  cold  water.  The  cooled  com- 
pressed air  is  then  liberated  with  the  effect  described.  Other 
apparatus  is  constructed  on  the  principle  of  ice  machines,  which  are 
operated  by  evaporating  ammonia,  which  produces  extreme  cold. 

The  keeping  of  meat  by  refrigeration  is  rapidly  superseding  the 
canning  process  for  this  kind  of  food,  over  which  it  has  many  decided 
advantages.  Between  15  and  20  per  cent  of  all  the  mutton  eaten  in 
Great  Britain  is  brought  from  New  Zealand  and  the  River  Plate  in 
a  refrigerated  condition. 

Captain  Woodruff,  U.  S.  Army,  writes :  *'  The  French  Govern- 
ment is  taking  the  initial  step  towards  applying  this  new  industry 
to  the  purposes  of  war.  They  have  succeeded  in  keeping  dressed 
beef  in  a  perfect  condition  for  three  or  four  months  with  the  present 
appliances. 

"A  moment's  thought  will  show  what  a  revolution  this  matter  of 
cold  storage  can  make  in  military  practices.  It  will  obviate  all 
necessity  of  keeping  live  cattle  near  the  army,  a  system  that  so 
often  results  in  diseased  animals  and  fatal  epidemics  among  the 
soldiers.  It  will  help  to  wipe  out  of  existence  all  the  salt  meats 
formerly  supplied,  and  will  thus  avoid  that  large  list  of  diseases  of 
stomach,  bowels,  and  nutrition  that  salt  meats  have  been  accused  of 
causing." 

VI.  Sterilisation. — By  sterilisation  of  food  is  meant  the  process 
of  rendering  it  germ-free  by  heat,  and  it  includes  the  preservation  of 
such  food  in  sterilised  vessels.  Practically  all  thoroughly  cooked 
food  is  for  the  time  being  "sterilised,"  and  overdone  meat  keeps 
longer    than    underdone   meat,   for    if  the   outer   layers   are   firmly 


FOOD  CONCENTRATION.- CONDENSED  FOODS.      257 

coagulated  and  dried  by  the  heat  of  boiling  or  roasting,  they  form 
an  envelope  which  is  less  pervious  to  the  atmospheric  air  and  germs 
(see  Cooking,  pages  240,  243). 

Canned  food  (see  below)  is  also  sterilised,  but  the  latter  term  is 
applied  chiefly  to  milk  which  has  been  treated  by  the  method  de- 
scribed on  page  73. 

VII.  Exclusion  of  Air. — Exclusion  of  air  from  contact  with 
food  is  accomplished  not  only  in  the  process  of  canning,  but  by  such 
means  as  varnishing  or  covering  it  with  substances  which  are  com- 
paratively impermeable,  as  in  the  case  of  varnishing  eggs,  covering 
fish  with  oil,  or /i/"/ with  lard,  etc. 

Eggs  undergo  decomposition  from  the  entrance  of  the  atmos- 
pheric air  and  germs  through  their  shells,  and  this  process  may  be 
prevented,  sometimes  for  several  years,  by  covering  fresh  eggs  with 
almost  any  substance  which  is  more  impermeable  than  their  shells, 
such  as  gum,  fat,  butter,  oil,  beeswax,  or  fresh  milk  of  lime.  The 
sawdust  or  salt  in  which  eggs  are  commonly  packed  serves  the 
double  purpose  of  insuring  safety  in  transportation  and  excluding  to 
some  degree  the  air.  Similarly  meat  may  be  preserved  by  coating  it 
with  paraffin,  gelatin,  collodion,  or  layers  of  powdered  charcoal  or 
of  lard  after  the  manner  of  potted  meats.  Beef  has  been  sent  in 
good  condition  from  Australia  to  England  by  merely  dipping  it  into 
hogsheads  of  melted  fat,  in  which  it  was  allowed  to  remain  after  the 
fat  cooled  and  solidified.  The  preservation  of  meats  in  air-tight 
skins,  like  sausages,  has  long  been  practised. 

When  food  is  preserved  by  any  of  these  methods  care  must  be 
exercised  to  have  it  perfectly  fresh  at  the  start  and  to  drive  off  by 
heat  or  otherwise  any  air  which  may  be  present  in  the  food  itself  or 
in  its  containing  vessel. 

Canning. — The  original  idea  of  the  preservation  of  foods  by  can- 
ning was  that  the  exclusion  of  air  was  the  sole  object  necessary  of 
accomplishment.  It  is  now  known,  however,  that  many  putrefactive 
bacteria  are  anaerobic,  and  that  the  food  must  be  thoroughly  steril- 
ised before  the  can  is  closed.  This  should  be  done  by  heat,  but 
since  it  can  also  be  accomplished  by  the  addition  of  antiseptics,  the 
introduction  of  the  latter  is  practised  by  some  unscrupulous  manu- 
facturers to  the  detriment  of  the  public  health. 

The  process  of  canning  meat  or  vegetables  is  conducted  as  fol- 
lows: The  food  is  placed  in  clean  new  tin  cans,  filling  them  as  com- 
pletely as  possible.  Lids  are  then  tightly  soldered  on  the  cans, 
leaving  a  minute  pinhole  opening  only  for  the  escape  of  air  and 
steam.  The  cans  are  then  immersed  in  a  bath  of  boiling  fluid,  such 
as  zinc-chloride  solution,  having  a  higher  boiling  point  than  the 
water  within  the  cans.  The  latter  boils,  expels  at  first  air,  then 
steam,  and  thoroughly  cooks  the  food,  making  it  aseptic  by  killing 


2c8^-  FOOD   PREPARATION   AND   PRESERVATION. 

all  germs.  Before  the  cans  cool,  their  minute  openings  are  soldered,^ 
and  they  are  then  ready  for  storage. 

The  long  boiling  of  meat  in  this  manner  toughens  its  fibres  by 
hardening  the  syntonin.  Such  meat  is  apparently  tender,  but  in 
reality  it  is  not  very  digestible  (Williams). 

To  avoid  the  necessity  of  cooking  food  at  a  high  temperature 
in  order  to  exclude  the  air,  various  modifications  in  the  process  of 
canning  are  employed.  One  of  these — McCall's — is  based  on  the 
disinfection  of  the  air  by  sodium  sulphite.  In  another  process  sul- 
phurous acid  and  nitrogen  are  used  to  replace  the  air. 

H.  W.  Wiley,  who  has  made  an  exhaustive  study  of  canned 
foods,  says,  in  an  instructive  report  on  Foods  and  Food  Adulter- 
ants, made  by  him  in  1893  for  the  United  States  Department  of 
Agriculture  (Bull.  No.  13,  Part  VIII) : 

"  All  manner  of  food  is  canned,  and  that  at  prices  which  place  it 
within  the  reach  of  the  humblest  pockets.  Preserved  food  has  been 
a  great  democratic  factor,  and  has  nearly  obliterated  one  of  the 
old  lines  of  demarcation  between  the  poor  and  the  wealthy.  Vege- 
tables out  of  season  are  no  longer  a  luxury  of  the  rich.  ...  In  the 
American  grocery  pineapples  from  Singapore,  salmon  from  British 
Columbia,  fruit  from  California,  peas  from  France,  okra  from  Lousi- 
ana,  sweet  corn  from  New  York,  string  beans  from  Scotland,  mut- 
ton from  Australia,  sardines  from  Italy,  stand  side  by  side  -on  the 
shelves." 

Much  light  is  thrown  by  Wiley  upon  the  economic  value  of  the 
substances  under  consideration  in  the  following  important  state- 
ments from  the  report  above  quoted  : 

"  The  quantity  of  dry  food  material  in  canned  goods  varies 
within  wide  limits.  It  is  very  low  in  such  vegetables  as  string 
beans,  asparagas,  etc.,  and  quite  high  in  such  materials  as  canned 
corn,  succotash,  and  other  bodies  of  that  description.  The  lowest 
percentage  of  dry  matter  in  string  beans  of  American  origin  was 
4.17.  In  other  words,  in  buying  one  hundred  pounds  of  such  ma- 
terial the  consumer  purchases  95.83  pounds  of  water. 

''  The  price  of  the  packages  of  string  beans  [bought  in  open 
market]  varied  within  wide  limits,  depending  both  upon  the  size  of 
the  packages  and  the  labels  they  bore.  The  highest  price  paid  was 
"thirty-five  cents,  and  the  weight  of  the  contents  of  the  package  was 
a  little  over  three  pounds.  The  lowest  price  paid  was  ten  cents,  and 
this  was  paid  in  many  instances.  The  highest  price  paid,  according 
to  the  percentage  of  dry  matter,  was  in  sample  10,928,  costing  thirty 
cents  and  containing  only  two  hundred  and  fifty-four  grammes  of 
string  beans,  31. i  grammes  of  dry  matter,  and  94.37  per  cent  of 
water.  The  price  of  the  dry  matter  in  this  package  was  nearly  one 
cent  per  gramme,  which  would  be  almost  five  dollars  per   pound. 


FOOD  CONCENTRATION.— CONDENSED  FOODS. 


259 


The  enormous  cost  of  food  in  canned  goods  is  illustrated  to  the 
fullest  extent  by  this  sample,  showing  in  a  striking  way  that  such 
food  materials  must  be  regarded  in  the  light  of  luxuries  or  condi- 
ments rather  than  as  nutrients  to  support  a  healthy  organism.  An 
expenditure  of  ten  or  fifteen  cents  for  a  good  article  of  flour  or  meal 
will  procure  as  much  nutriment  for  a  family  as  the  investment  of 
three  or  four  dollars  in  canned  goods  would. 

"A  general  view  of  the  digestive  experiments  must  lead  to  the 
conviction  that  the  process  of  canning,  especially  when  preservatives 
are  employed,  such  as  salicylic  acid  and  sulphites,  tends  to  diminish 
the  digestibility  of  the  albuminoid  and  other  bodies.  The  low  per- 
centage of  digestible  albuminoids  will  be  remarked  with  some  degree 
of  astonishment  in  all  the  analytical  tables." 

Of  the  dangers  of  poisoning  from  canned  foods  Wiley  says  :  "  Veg- 
etables are  usually  canned  in  the  fresh  state,  and  if  they  are  in  any 
degree  spoiled  at  the  time  the  fact  is  usually  conspicuously  evident 
to  the  taste,  so  that  the  canner  cannot  afford  to  use  them.  Bacterial 
action  seldom  occurs  in  the  can  without  bursting  it  or  rendering  it 
unsalable.  Ptomaines  may,  however,  develop  where  the  canned  food 
is  allowed  to  stand  for  some  time  after  opening,  though  even  then 
this  is  unlikely  in  the  case  of  preserved  vegetables. 

"  It  may  be  said,  therefore,  that  the  principal  risks  to  health  which 
may  arise  from  the  use  of  canned  goods  are  those  due  to  the  use  of 
preservatives,  or  to  the  presence  of  the  heavy  metals — copper,  tin, 
lead,  and  zinc.  ...  In  this  country  there  is  no  restriction  whatever 
in  regard  to  the  character  of  the  tin  employed,  and  as  a  result  of  this 
the  tin  of  some  of  the  cans  has  been  found  to  contain  as  high  as  12 
per  cent  of  lead.  .  .  .  The  analyses  of  numerous  samples  of  solder 
employed  show  that  it  contains  fully  50  per  cent  of  lead.  In  addi- 
tion to  this  there  is  no  care  taken  to  prevent  the  solder  from  coming 
in  contact  with  the  contents  of  the  can.  It  is  a  rare  thing  to  care- 
fully examine  the  contents  of  a  can  without  finding  pe?llets  of  solder 
somewhere  therein. 

"Another  great  source  of  danger  from  lead  has  been  disclosed  by 
the  analytical  work,  viz.,  in  the  use  of  glass  vessels  closed  with  lead 
tops  or  with  rubber  pads,  in  which  sulphate  of  lead  is  found  to  exist." 

The  frequency  of  poisoning  by  eating  canned  lobster,  crabs,  or 
shellfish  is  due  mainly  to  the  rapidity  with  which  they  decompose 
and  develop  ptomaines  after  the  can  has  been  opened.  The  contents 
of  such  a  can  partially  used  should  not  be  kept  until  the  next  day. 

VIII.  Antiseptic  and  Preservative  Substances.— A  long  list 
of  chemical  substances  have  been  used  from  time  to  time  in  the  pres- 
ervation of  food,  but  most  of  them  have  been  supplanted  by  the 
safer  process  of  canning,  refrigeration,  etc. 

The  use  of  various  antiseptic  or  preservative  fluids  is  designed  to 


26o  FOOD   PREPARATION   AND   PRESERVATION. 

prevent  the  activity  of  germs  and  fermentation.  Sugar,  like  salt,  in 
strong  solution  possesses  decided  antiseptic  powers,  and  hence  the 
employment  of  strong  sirups  for  the  preservation  of  fruits,  and  of 
sugar  itself  in  making  candied  fruits.  Other  harmless  preservative 
materials  which  are  added  are  oils,  chiefly  serviceable  for  keeping 
fish,  and  vinegar  and  spirits  of  wine  for  pickling  such  products  as 
chilies,  tarragon,  and  shallot. 

Vinegar  is  used  to  preserve  oysters,  lobsters,  and  other  sea  food, 
as  well  as  cucumbers,  cauliflower,  and  other  vegetables,  as  "pickles." 
Spices,  mustard,  and  similar  condiments  are  usually  added. 

"  Soused  "  fish,  such  as  mackerel,  are  "immersed  in  mixtures  of  cider 
vinegar  flavoured  with  cloves,  nutmeg,  parsley,  bay,  onions,  etc. 
After  being  "  soused  "  once  or  twice  the  food  is  heated  in  the  fluid  to 
140°  F.,  flavouring  substances  are  added,  such  as  Worcestershire 
sauce,  extract  of  anchovy,  and  lemons,  and  the  whole  is  put  in  air- 
tight jars  (Clark). 

Among  the  materials  sometimes  employed  for  preserving  foods 
may  be  mentioned  the  fumes  of  burning  sulphur  (sulphurous  acid), 
acetic  acid,  weak  carbolic  acid,  bisulphite  of  calcium,  and  the  injec- 
tion into  the  blood  vessels  of  meat  of  alum,  chloride  of  aluminum,  etc. 
Borax,  boric  and  salicylic  acids,  and  other  materials  have  been  ex- 
tensively used  in  the  preservation  of  milk,  beer,  meats,  etc. 

A  new  method  of  meat  preservation  has  been  introduced  by  Mr. 
Jones  in  England.  It  consists  of  injecting  the  animal  the  moment 
after  it  is  killed  with  a  solution  of  borax,  which  is  so  uniformly  dis- 
tributed through  the  circulation  to  all  the  fibres  of  the  meat  that  but 
a  very  small  quantity  of  the  antiseptic  need  be  employed. 

Glycerin  has  been  used  as  a  preservative,  but  it  cannot  be  em- 
ployed in  any  quantity  on  account  of  its  aperient  action.  Carbonate 
of  soda  and  sugar  added  to  milk  will  preserve  it  for  ten  or  twelve 
days  (Yeo). 

It  is  true  of  practically  all  of  these  latter  substances  that  food 
preserved  by  them  if  used  in  excess  or  for  any  length  of  time  is  apt 
to  endanger  the  normal  digestive  functions,  besides  being  somewhat 
less  nutritious  and  more  tasteless  than  other  preparations.  The  use 
of  many  of  them  has  been  suppressed  by  law  on  account  of  their 
injurious  properties,  and  the  addition  of  salicylic  acid  to  beer,  milk, 
and  other  forms  of  animal  food  is  everywhere  condemned. 

Substitutes  for  Food. 

Men  are  often  placed  under  conditions  in  which,  from  poverty  or 
exposure,  sufficient  quantities  of  food  cannot  be  obtained.  Under 
these  circumstances,  the  craving  of  hunger  may  be  diminished  and 
the  actual  tissue  waste  may  be  retarded  by  the  substitution  of  cer- 
tain mild  stimulants  and   beverages.     Tea,  coffee,  and  tobacco  all 


FOOD   CONCENTRATION.— CONDENSED   FOODS.  261 

possess  moderate  action  in  this  respect,  and  alcohol,  under  such 
conditions,  is  both  a  stimulant  and  a  food.  The  natives  of  various 
barbarous  or  semicivilised  countries,  while  performing  long  feats 
of  marching,  being  often  unable  to  obtain  sufficient  food  with  regu- 
larity, make  use  of  a  variety  of  different  substances  for  the  purpose 
above  indicated.  Among  these  may  be  mentioned  betel  nut,  kola 
nut,  Siberian  fungus,  the  cocoa  leaf,  and  pepperwort,  which  are 
chewed  from  time  to  time ;  hasheesh  and  opium,  which  are  both 
eaten  and  smoked ;  mate,  and  various  forms  of  alcoholic  fermented 
drinks.  All  these  substances  are  used  to  enable  men  to  prolong 
periods  of  fasting. 

Quantity  of  Food  Required. 

The  quantity  of  food  required  to  maintain  the  body  in  vigour  de- 
pends upon  the  following  conditions  : 

I.  External  temperature.  2.  Climate  and  season.  3.  Clothing. 
4.  Occupation,  work,  and  exercise.  5.  The  state  of  individual 
health.     6.  Age.     7.  Sex. 

In  civilised  communities,  where  cooking  is  a  fine  art,  the  number 
and  variety  of  food  preparations  is  so  great  that  the  appetite  is 
often  stimulated  beyond  the  requirements  of  the  system,  and  conse- 
quently more  food  is  eaten  than  is  necessary  or  desirable  to  maintain 
the  best  standard  of  bodily  health  and  vigour. 

Persons  in  this  country  who  live  in  comfortable  circumstances 
often  eat  a  dozen  or  fifteen  ounces  of  solid  food  at  breakfast,  and 
again  at  luncheon,  and  perhaps  thirty  ounces  more  at  dinner,  making 
a  total  of,  say,  fifty-five  or  sixty  ounces,  to  which  are  added  only 
fifty  or  fifty-five  ounces  of  fluids.  This  is  about  a  third  more  than 
the  amount  of  solids  actually  needed,  forty  ounces  of  solid  food 
(which  equals  twenty-three  ounces  of  water-free  food)  being  a  fair 
average  for  the  daily  necessities  of  most  persons,  one  fourth  of  which 
should  be  animal  and  three  fourths  vegetable  food.  They  eat.  too 
much  and  drink  too  little  fluid  in  proportion  (see  Water,  page  15). 

Gluttony  results  in  overdevelopment  and  overwork  of  the  digest- 
ive apparatus.  The  stomach  and  bowels  become  enlarged,  the  liver 
is  engorged,  and  a  predisposition  is  established  to  degenerative 
changes,  fatty  heart,  etc.  (see  Overeating), 

The  most  northern  Eskimos,  for  example,  who  often  eat  but  one 
meal  a  day  and  then  gorge  themselves  with  tough  meat,  develop  big 
jaws  and  distended  abdomens  (Cooke).  Hayes  described  Eskimos 
who  ate  daily  from  twelve  to  fifteen  pounds  of  food,  about  one  third 
of  which  was  fat,  and  the  rest  mostly  meat;  and  Captain  Hall,  when 
on  his  arctic  expedition,  declares  that  he  saw  a  native  consume 
twenty  pounds  of  raw  meat  and  drink  a  quart  of  train  oil  within 
twenty-four  hours. 


263  FOOD   PREPARATION*   AND   PRESERVATION. 

It  is  stated  by  competent  students  of  dietetics  that  more  disease 
arises  from  abuse  of  food  in  regard  to  both  quantity  and  quality  than 
from  abuse  of  drink. 

Sir  H.  Thompson  says  (Diet  in  Relation  to  Age  and  Activity): 
'*  More  mischief  in  the  form  of  actual  disease,  of  impaired  vigour/ 
and  of  shortened  life  accrues  to  civilised  man,  so  far  as  I  have  ob- 
served in  our  own  country  and  throughout  western  and  central  Eu- 
rope, from  erroneous  habits  in  eating  than  from  the  habitual  use  of 
alcoholic  drink,  considerable  as  I  know  the  evil  of  that  to  be." 

1.  The  external  temperature  increases  the  rate  of  oxidation  pro- 
cesses in  the  body  as  it  becomes  colder  by  stimulating  the  respira- 
tion and  circulation,  and  there  is  a  consequent  increased  demand  for 
food. 

2.  Climate  and  season  influence  the  quantity  of  food  eaten. 
Cold,  bracing  atmosphere  stimulates  the  appetite,  tempts  one  to 
exercise  vigorously,  and  hence  demands  a  larger  consumption  of 
fuel  or  food.  A  hot  climate  or  season,  with  enervating,  moist  air, 
disposes  man  to  languor  and  inactivity,  and  diminishes  the  appetite 
as  well  as  the  need  for  food. 

3.  Abundant  clothing  in  a  cold  climate  conserves  the  body  heat, 
and  less  food  is  therefore  required  to  maintain  life  than  if  the  body 
is  but  scantily  clad. 

4.  Exercise  and  muscular  work  also  promote  oxidation  in  the 
tissues  and  augment  waste  production  from  the  muscles.  This 
waste  must  be  replaced,  and  energy  must  be  supplied  for  work  by 
additional  consumption  of  food.  Outdoor  work  demands  more  food 
than  indoor  work,  and  mental  labour  less  than  physical.  Where 
men  are  fed  upon  a  carefully  regulated  diet — as  in  prisons — it  is 
found  that  those  who  are  performing  hard  labour  require  about  one 
fifth  more  solid  food  than  the  others.  The  hard-labour  prison  diet- 
ary in  England  comprises  fifty  ounces  of  solid  food,  chiefly  bread 
and  vegetables  (see  Diet  in  Prisons,  page  688). 

5.  The  state  of  health  of  the  individual  greatly  modifies  the 
amount  of  food  required  both  indirectly,  through  influencing  exer- 
cise and  work,  and  directly,  by  the  local  condition  of  the  digestive 
system. 

Feeble  and  inactive  persons  may  live  on  a  third  or  less  of  the 
ordinary  ration.  Patients  having  chronic,  purulent  discharges,  such 
as  come  from  old  sinuses,  empyema,  and  tubercular  abscesses,  need 
large  quantities  of  food — if  they  can  digest  it — lo  maintain  their 
strength  against  the. constant  drain  on  their  systems. 

The  nursing  mother  should  have  abundant  food,  for  she  must 
eat  for  two. 

6.  The  age  of  the  individual  not  only  modifies  the  absolute 
amount  of  food  required,  but  also  the  relative  quantity  in  proportion 


FOOD  CONCENTRATION.— CONDENSED  FOODS.      263 

to  body  weight.  In  the  first  year  of  life  the  infant  grows  six  or 
eight  inches,  and  at  the  end  of  a  twelvemonth  it  should  weigh 
two  or  three  times  as  much  again  as  at  birth.  This  rapid  growth 
necessitates  a  relatively  larger  consumption  of  food  than  at  any 
other  period  of  life,  and  hence  the  child  is  fed  at  first  once  every 
two  hours,  and  later  every  three  hours.  During  the  second  year  the 
proportionate  growth  is  half  that  of  the  first  year,  and  during  the 
third  year  it  is  one  third  that  of  the  first.  After  the  third  year  the 
weight  and  growth  mcrease  more  uniformly,  but  the  child  must  still 
have  a  large  relative  quantity  of  food,  a  great  proportion  of  which 
must  be  tissue-forming — i.  e.,  nitrogenous. 

In  infant  feeding  in  the  earlier  months  of  life  it  is  advisable  to 
weigh  the  child  frequently  and  measure  all  its  nourishment*,  in  order 
that  a  definite  ratio  may  be  maintained  between  growth  and  food 
consumption. 

A  child  of  ten  years  requires  half  as  much  food,  and  one  of  four- 
teen years  about  as  much  as  a  grown  woman.  The  rapidly  growing, 
active  boy  often  eats  more  animal  food  than  the  adult,  and  the 
middle-aged  man  eats  more  than  the  aged.  A  man  of  seventy  years 
may  preserve  good  health  on  a  quantity  of  food  which  would  soon 
starve  his  grandson. 

7.  Sex  influences  to  a  considerable  extent  the  quantity  of  food 
consumed,  but  allowance  must  be  made  for  totally  different  habits 
of  life.  There  are  many  women  who  eat  as  much  as  men,  but  the 
majority  require  less  food,  even  when  doing  the  same  work.  Under 
equal  c'onditions  in  penal  institutions  men  require  about  one  fifth 
more  solid  food  than  women.  Female  factory  operatives  eat  from 
one  tenth  to  one  fifth  less  food  than  men. 

Mrs.  E.  H.  Richards,  as  the  result  of  observations  (Food  as  a 
Factor  in  Student  Life)  upon  130  young  women  students  at  the  Uni- 
versity of  Chicago,  whose  average  weight  was  120  pounds,  gives  the 
following  table  of  food  consumption  in  grammes/^/-  diem : 

Proteid 120 

Fat 161 

Carbohydrates 402 

Total ' 659 

Potential  energy  in  calories 3.383 

Women,  on  the  average,  weigh  less  than  men,  take  less  exercise, 
work  less,  and  live  less  in  the  open  air,  and  hence  require  less  food. 
As  a  consequence  of  their  habits  of  life  they  are  more  liable  to  dys- 
pepsia and  constipation,  which  are  also  factors  in  reducing  the  quan- 
tity of  their  food  below  the  standards  for  men.  There  are  naturally 
many  exceptions  to  all  these  general  statements. 

It  is  ordinarily  impossible  or  impracticable  to  definitely  weigh  the 
food  for  individual  consumption,  but  where  large  numbers  of  men 


264 


FOOD  PREPARATION  AND  PRESERVATION. 


are  being  fed  by  contract  in  institutions,  or  as  sailors  or  soldiers,  or 
on  exploring  expeditions,  it  becomes  necessary  to  estimate  carefully 
the  quantity  of  food  required /<?/-  diem  to  maintain  normal  health  and 
vigour.  To  facilitate  such  estimates,  tables  have  been  carefully  com- 
puted based  upon  the  nutrient  value  of  different  foods. 

Quite  exceptionally,  persons  are  observed  who  subsist  in  good 
health  upon  an  abnormally  small  quantity  of  food.  They  usually  do 
but  little  work,  and  they  are  often,  but  not  always,  advanced  in 
years  (see  Food  in  Old  Age,  page  285). 

Fothergill  referred  to  the  case  of  one  Wood,  a  miller  of  Billericay, 
who  for  eighteen  years  subsisted  solely  upon  a  daily  allowance  of 
sixteen  ounces  of  flour,  which  he  ate  as  sea  biscuit  made  into  a  pud- 
ding. B^  this  diet  he  reduced  his  figure  from  extreme  corpulency  to 
normal  size,  and  maintained  good  bodily  vigour. 

In  the  preparation  of  food  to  be  eaten  it  is  customary  to  allow  10 
per  cent  of  waste  in  calculating  the  gross  quantity  for  dietaries  of 
institutions,  army  rations,  etc.  Mrs.  E.  H.  Richards  found  that 
this  percentage  is  somewhat  too  low. 

In  computing  the  quantity  of  food  needed  for  daily  consumption 
its  composition  must  be  taken  into  account.  The  estimates  of  differ- 
ent authors  vary  somewhat  in  regard  to  the  necessary  quantity  of 
different  kinds  of  food  in  a  mixed  diet,  but  notwithstanding  this 
there  is  a  general  correspondence  between  them.  The  chief  dis- 
crepancy concerns  the  amount  of  fat  to  be  eaten,  and  it  will  be 
noticed  in  the  following  tables  that,  as  a  rule,  when  the  fat  is  cut 
down  the  carbohydrate  estimate  is  correspondingly  increased. 


Standard  Daily  Diet  for  an  Adult  Male  at  Ordinary  Work. 
Computed  in  grammes. 


Mole- 
schott. 

Pettenkofer 
and  Voit. 

Ranke. 

Play- 
fair. 

Foster. 

Lan- 
dois. 

Dujardin- 
Beaumetz. 

Albuminates 

130 
84 

404 
30 

648 

137 

117 

352 

30 

100 
100 
240 

25 

119 
530 

133 

95 

422 

120 

90 

330 

124 

55 
430 

Fats 

Carbohydrates 

Sahs 

Total  water-free  food. . . 

636 

465 

700 

650 

540 

609 

Healthy  Adult  Man,  Abundant  Diet  and  Rest  (Bauer). 


Taken  in. 

Consumed. 

Stored  up. 

Albumin 

137 
117 
352 

137 

52 
352 

Fat 

65 

Carbohydrates 

FOOD   CONCENTRATION.— CONDENSED   FOODS. 


265 


An  Ideal  Ration  of  Solid  Food  (Mrs.  E.  H.  Richards). 


Material. 


Bread 

Meat 

Oysters 

Breakfast  cocoa. 

Milk 

Broth 

Sugar 

Butter 


Total . 


Grms.       Oz, 


453-6 

226.8 

226.8 

28.3 

II3-4 

453.6 

28.3 

14.17 


16 


Grms. 


31-75 
34.02 
12.52 
6.60 
3-63 
18.14 

0.14 


106 . 80 


Oz. 


1. 12 
1.20 
0.44 
0.23 
0.13 
0.64 


CARBOHYDRATES. 


Grms. 


2.26 

"•34 
2.04 
7-50 
4.42 

18.14 

12.27 


Oz. 


Grms. 


57-97 


o.o3 
0.40 
0.07 
0.26 
0.16 
0.64 


257 


389 


28 


84 


Oz. 


4.04 


0.34 
0.17 
3-20 
0.96 


Calories. 


1,206.82 
243.72 

70.01 
135-42 

75-55 
613.21 
112. 17 
118.62 


2,574.60 


An  Ideal  Ration  of  Liquid  Food  (Mrs.  E.  H.  Richards). 


Material. 


Beef  broth  or  consommi. 

To  which   has   been   added   one 

large  egg,  minus  shell 

Dried  fruit  soup 

Lemon  jelly 

Whole  milk 

Rice  or  arrowroot 

Grape  sugar,  or  some  one  of  the 

prepared  foods  (dry) 


Total. 


Amount. 


1  pint. 

2  oz. 

I  quart, 
i  pint. 
1  quart. 

3  oz.  (dry). 

4  oz.  (dry). 


2  •  5  quarts  to 
3.0  quarts.* 


Proteid. 


Grammes. 
20.5 

7-1 

"6^5 

34-0 

6-3 

2.5 


76.9 


Fat. 


Grammes. 
0.5 


6.8 


36.0 
0-3 


43-6 


Carbo- 
hydrates. 


lOO.O 
12.5 

44.0 
67.2 

lOO.O 


323-7 


Calories. 


88. 70 

91.67 
410.00 

77.90 
651.00 
304  - 1 1 

420.25 


2,043.63 


*  According  to  how  the  rice  is  given. 
A  Common  Invalid  Ration  too  Low  in  Proteid  (Mrs.  E.  H.  Richards). 


I  pint  of  beef  broth  or  consommi 

I  pint  of  dried  fruit  soup 

I  pint  of  lemon  whey 

1  pint  of  Imperial  Granum,  containing  3  oz. 

2  quarts  of  liquid.     Total 


Proteid. 


Grammes 
20.5 


6.8 


27-3 


Fat. 


Carbo- 
hydrates. 


Grammes.  Grammes. 
0.5 


21.5 
0.4 


22.4 


50 

79 
64 


193 


Calories. 


88.7 
205.0 
521.7 
294.0 


1,109.4 


A  Ration  Rich  in  Proteid— after  Acute  Disease  (Mrs.  E.  H.  Richards). 


Materiau 


Bread 

Meat 

Milk  without  cream 

Coffee  or  tea  with  cream. 

Butter 

Sugar 


Less  lo  per  cent  for  indigestibility 
Total 


Amount. 


Grms. 
453-6 
453-6 
453-6 
453-6 
14.17 
56-7 


Proteid. 


Grammes. 

31-75 

64.04 

29.02 

4.60 

0.14 


129.55 
12.95 


116.60 


Fat. 


Grammes. 
2.26 
22.68 
18.00 

3-25 
12.27 


58.46 
5-84 


Carbo- 
hydrates. 


Grammes. 
257.28 

39-00 
I.  14 

54-72 


352-14 

35-21 


52.62  j  316.93 


Calories. 


1,205.81 
487.62 
444.48 

53-43 
118.62 

224-35 

2,746.12 
274.61 


2,534.31 


•266 


FOOD  PREPARATION  AND  PRESERVATION. 


Table  cofnpiled  by  Mrs.  E.  H.  Richards  and  Miss  Marion  Talbot, 

One  day's  food,  March  17th,  at  the  University  of  Chicago,  calculated  to  determine 
the  amounts  and  proportions  of  the  various  constituents  and  their  comparison  with  the 
general  average. 


Pounds. 

Per  cent 
proteid. 

Per  cent 
fat. 

Per  cent 
carbo- 
hydrate. 

Pounds 

proteid 

net. 

Pounds 
fat  nel. 

Pounds 
carbo- 
hydrate 
net. 

Calo- 
ries. 

50.0 
90.0 
45 -o 

4.0 
77.0 

3-0 

192.0 

13.0 

15.0 

15.0 

6.0 

9.0 

Stew  and  cold  meat. 

White  potatoes 

Sweet  potatoes 

Dried  beef 

21.0 
1.8 

1-5 
340 

II-5 
1-3 
3-5 
3-0 
2.0 

8.0 
0.2 
0.4 

7-5 
1.8 

3-7 
12.0 
83.0 

19. 1 
26.0 

70.0 
83.0 

4-7 

3-0 

0.5 

96.5 

65.0 

II. 0 

19.7 

10.5 
1.6 
0.7 
1.4 
8.9 

* "  6.8  * " 
0.4 
0.3 

4.0 

o.iS 
0.  2 

0.3 
1.4 

7-1 

1.6 

12.5 

17.2 
II. 7 

Flour  and  grain 

Tapioca 

53-9 
2.5 
9.0 
0.4 

Milk 

Cream 

Butter 

Sugar 

14-5 
4.0 

0.8 

5-0 

Prunes 

Oranges,  less  20  per 

cent  waste 

Bananas,  less  50  per 

cent  waste 

Eggs 

3-5 

I.O 

4-85 
12.5 
20.0 
19.0 
15-0 

12.0 

I5-0 

5.0 

•22.0 

0.2 

50.0 

7.2 

41.0 

26   0 

1-3 
0.^ 
8.2 
5-0 
2.1 

' '  0.8  ' " 
6.2 
1-3 
3-1 

Lamb 

Turkey 

14.0 

Steak 

657-2 

76.0 

48.3 
7-9 

38.68 
2.06 

119. 0 
23-6 

(Less    turkey,    lamb, 
and  bread  left  over) 

581.2 

Divided  by  130 

40.4 

36.62 

95-4 

4.4 

Per  person,  nutrients. 

0.310 

Grammes. 
126.5 

0.281 

Grammes. 

114. 7 

0-733 

Grammes. 
332-0 

2,946 
2,953 

Daily  average  for  the 
6  months,  nutrients 

108.0 

102.0 

381.0 



Average  Daily  Dietary  for  an  Adult  Man  (Dujardin-Beaumetz). 

Albuminates 124  grammes. 

Carbohydrates 430         " 

Fat 55 

This  would  correspond  with  a  bread-and-meat  ration  of — 

White  bread 819  grammes  (about  28  oz.). 

Meat 259         "         (about  9  oz.). 

As  a  fair  average  for  computation  it  may  be  said  that  300  grains 
of  nitrogen  and  4,800  grains  of  carbon  are  daily  required. 

In  order  to  obtain  the  nitrogen  necessary  for  the  system  from  a 
diet  composed  exclusively  of  starchy  food — as,  for  example,  pota- 
toes— it  would  be  necessary  to  eat  ten  pounds.     If  bread  alone  is 


FOOD   CONCENTRATION.— CONDENSED   FOODS. 


267 


eaten,  four  pounds  would  be  required,  and  this  contains  more  than 
twice  the  amount  of  carbon  needed.  About  fifteen  pounds  of  cab- 
bage would  have  to  be  eaten  for  the  same  purpose.  On  the  other 
hand,  to  obtain  sufficient  carbon  from  an  exclusive  meat  diet  at  least 
si.x  pounds  of  beef  must  be  consumed.  If  eggs  were  used  exclusively, 
about  twenty-three  pounds  would  have  to  be  eaten. 

The  following  diagram  was  kindly  furnished  me  for  reproduction 
by  Mrs.  Ellen  H.  Richards,  with  the  remark  that  it  gives  "  only  an 
approximate  statement  of  observed  facts  "  : 


( 

Years  of  age 

)        4        8       1 

2       16      20      24      28      32      36     JO       44      48       52     36      60      C4      63      7 

2   \ 

6    80 

500 
.460 

^ 

1 — 

J 

X 

X, 

i 

/ 

\ 

s 

380 

isJO 
0 

^300 

M 

=260 

in 

0 

E220 

E 

140 
100 
60 
20 

; 

i/ 

V 

N 

' 

X 

N 

/ 

N 

N, 

/ 

, 

> 

\ 

/ 

\ 

/ 

/ 

<)5 

p.' 

"■^ 

■^ 

— 

L. 

, 

/ 

L^ 

f*tS 

^-^ 

^ 

-^ 

,^ 

k 

■ — 

^ 

^ 

"^ 

^> 

"~^ 

^ 

The  following  table  from  Landois  and  Stirling  is  arranged  to 
show  the  total  quantity  of  each  single  food  which  it  would  be  neces- 
sary to  eat  in  order  to  obtain  the  requisite  proteids  on  the  one  hand 
(column  A)  and  the  requisite  carbohydrates  on  the  other  (column  B), 
For  the  purpose  of  comparison  these  authors  estimate  the  necessary 
daily  amount  of  carbohydrates  at  448  grammes  and  the  necessary 
proteids  at  130  grammes  : 


B. 


Rice 

Wheat  bread 

Lentils 

Peas 

Eggs 

Rye  bread . . , 

Cheese 

Potatoes 

Beef 


2,562  grammes. 

572  grammes 

1.444 

625         " 

491 

806 

582         " 

819 

968 

902         " 

2,875         " 

930 

388 

2,01  r        " 

10,000 

2,039        " 

614         " 

2,261 

268  FOOD    PREPARATION   AND   PRESERVATION. 

If  a  man  doing  hard  labour  were  to  attempt  to  live  upon  milk 
alone  he  would  require  fully  ten  pints  a  day  to  obtain  the  carbon 
necessary.  Either  of  these  quantities  of  food  constitutes  an  exces- 
sive bulk  and  greatly  overtaxes  the  digestive  system.  In  fact,  it 
would  be  wholly  impossible  for  most  people  to  eat  meals  of  this' 
character.  The  food  would  be  too  heavy  ;  it  would  take  too  long  a 
time  to  consume  it,  and  it  would  be  too  monotonous.  It  becomes 
absolutely  essential,  therefore,  for  man  to  so  regulate  the  composi- 
tion of  his  diet  as  to  properly  balance  its  essential  chemical  ele- 
ments. This  balance  is  best  secured  by  a  diet  in  which  nitrogen 
bears  the  relation  to  carbon  of  i  to  3.5  or  4.  In  bread  the  propor- 
tion of  carbon  to  nitrogen  is  3.0  to  i,  and  in  meat  it  is  reversed,  and 
stands  i  to  3.5. 

It  is  also  more  economical  for  the  workingman  to  have  fats  and 
sugar  in  his  diet  and  not  to  live  exclusively  on  meat.  The  con- 
tractor soon  learns  that  ill-fed  men  do  poor  and  insufficient  work. 
The  force  must  be  developed  out  of  the  latent  energy  of  matter 
whether  bricks  are  to  be  carried  to  the  top  of  a  building  by  a  man  or 
a  hoisting  machine.  The  carbon  of  coial  is  oxidised  to  develop  force 
for  lifting  through  the  engine.  The  carbon  in  all  the  forms  of  fats, 
starches,  and  sugars  is  utilised  in  the  body  of  man  to  enable  him  to 
do  the  same  work.  The  labourer  does  right  therefore  when  he  eats 
bacon  with  his  cabbage  and  treacle  with  his  oatmeal.  There  is  one 
fallacy  in  the  above  comparison  that  must  not  be  overlooked,  which 
is  that  the  more  fuel  the  machine  consumes,  the  more  work  it  doe4; 
this  applies  to  man  only  within  narrow  limits,  and  too  large  a  quan- 
tity of  food  promptly  brings  him  into  trouble  with  his  digestive 
organs  (see  Overeating,  page  342). 

The  amount  of  nutrient  material  required  per  diem  by  a  healthy 
adult  male  doing  moderate  manual  labour  is  summed  up  as  follows: 

Atwater. 


Protein 118  grammes.  125  grammes. 

Fat 56        "  125         " 

Carbohydrates 500         "  450         " 

This  proportion  is  repres.ented  by  Billings  as  follows : 

Lean  meat 20  ounces. 

Bread 22      " 

Potatoes 10      " 

Three  or  four  cups  of  coffee. 

According  to  Chambers,  the  average  adult  at  ordinary  labour 
obtains  enough  food  in  a  day  if  he  eats  one  pound  of  meat  and  two 
pounds  of  bread  or  its  equivalent,  provided  no  peculiarities  of  size, 
health,  or  climate  are  to  be  accounted  for. 


FOOD  CONCENTRATION.— CONDENSED  FOODS.      269 

Moleschott  estimates  the  daily  quantity  of  food  required  exclu- 
sive of  water— i.  e.,  "dry  food  "—at  23  ounces,  one  fifth  of  which 
should  be  protein.  The  average  amount  of  water  contained  in  the 
food  of  a  mixed  diet  may  be  estimated  at  about  45  or  50  per  cent, 
although  it  may  reach  60  per  cent.  Therefore  the  23  ounces  of  dry 
food  is  the  equivalent  of  46  or  48  ounces  of  food  as  ordinarily  eaten. 
The  average  percentage  of  water  in  bread  is  37  per  cent ;  in  cooked 
meat,  54  per  cent ;  in  vegetables,  70  per  cent  or  more  (Letheby). 

"Assuming  the  average  to  be  23  water-free  ounces  daily  and  the 
mean  weight  to  be  150  pounds,  the  body  receives  %<^  of  its  own 
weight  in  water-free  solids.  The  range  in  different  persons  is  'j^  to 
y,^  of  the  body  weight  "  (Parkes). 

This  problem  may  be  differently  stated,  reckoning  in  the  water 
with  the  solid  food  as  follows: 

A  robust  man  weighing  144  pounds  may  consume  '/^  of  his  body 
weight,  or  6  pounds,  in  nourishment  per  diem,  divided  as  follows: 
Inorganic  food,  water,  and  salts,  3.5  pounds. 

Organic  food  (animal  food,  i  pound  ;  vegetable  food,  1.5  pound), 
2.5  pounds. 

It  is  usually  better,  unless  active  exercise  is  being  taken,  to  eat  a 
little  less  meat  and  more  vegetable  food,  as  previously  stated,  and 
to  drink  a  little  more  fluid. 

The  average  amount  of  dry  food  by  weight  required  for  breakfast 
may  be  put  at  8  ounces,  for  luncheon  6  ounces,  for  dinner  9  ounces. 
The  "middle  diet"  at  Guy's  Hospital,  which  is  supplied  to  the  ma- 
jority of  the  patients,  furnishes  29.5  ounces  of  solid  food  per  diem 
in  addition  to  liquids.  Of  course  such  persons  are  taking  no  active 
exercise.  This  is  equivalent  to  17  ounces  of  dry  or  water-free  food. 
It  consists  of  4  ounces  of  meat  (cooked),  12  ounces  of  bread,  8  ounces 
of  potatoes,  i  ounce  of  butter,  0.75  ounce  of  sugar,  0.25  ounce  of  tea, 
and  2.5  ounces  of  milk. 

Nitrogenous  material  should  constitute  "one  fifth  of  the  water- 
free  food,  or  from  4  to  5  ounces  for  active  life.  The  ordinary  meat 
ration  for  soldiers  is  12  ounces  per  diem,  of  which  20  per  cent,  or  2.4 
ounces,  is  deducted  for  waste  of  bone,  tendon,  etc.  For  inactive  life, 
from  3  to  3.5  ounces  "  (Pavy).  This  diet  will  completely  replace  the 
nitrogen  eliminated  from  the  body.  "  Two  pounds  of  bread  and  three 
fourths  of  a  pound  of  uncooked  beef  contain  as  nearly  as  possible  the 
right  proportion  of  carbon  and  nitrogen."  This  makes  44  ounces  of 
solid  food.     Water-free  meat  contains  about  0.20  per  cent  nitrogen. 

Fat  added  to  the  daily  diet  in  the  proportion  of  about  one  ounce 
of  butter  not  only  supplies  necessary  force  and  tissue  elements,  but 
acts  favourably  in  promoting  the  proper  assimilation  of  the  other 
classes  of  food  and  diminishing  to  a  great  extent  the  wear  and  tear 
of  the  tissues.     The  scrofulous  diathesis  has  been  attributed  in  great 


270 


FOOD  PREPARATION  AND  PRESERVATION. 


part  to  an  insufficient  quantity  of  fatty  food.  With  active  work,  es- 
pecially in  a  cold  atmosphere,  more  than  double  this  amount  is  con- 
sumed with  advantage,  and  even  2.5  ounces  form  an  average  allow- 
ance for  many  classes  of  workmen. 

The  carbohydrates  are  required  in  quantities  between  14  and  22 
ounces,  their  main  use  being  to  convey  energy  for  heat  and  mechan- 
ical v/ork. 

The  quantity  of  mineral  matter  for  daily  use  varies  from  0.5  to  i 
ounce.  This  quantity  is  less  affected  by  conditions  of  temperature 
and  exercise  than  are  other  food  constituents.  Chaumont  estimates 
that  a  man  of  150  pounds  can  do  an  average  day's  work  upon  a  diet 
of  albuminoids,  4.5  ounces;  fats,  3.75  ounces;  carbohydrates,  18 
ounces;  and  salts,  !'/„  ounce.  These  estimates  are  of  water-free 
constituents. 

Water. — The  amount  of  water  drunk /^r  diem  is  usually  less  than 
should  be  taken.  Many  persons  believe  that  it  is  injurious  to  drink 
much  fluid  with  their  meals  and  forget  to  take  any  between,  and 
as  a  result  not  enough  water  is  consumed  to  thoroughly  dissolve  and 
eliminate  the  waste  matter  of  the  system.  The  average  quantity  of 
urine  voided  is  52  ounces,  10  ounces  more  are  lost  from  the  surface  of 
the  lungs,  and  18  ounces  from  the  skin.  This  total  of  80  ounces 
must  be  daily  replaced  to  maintain  the  equilibrium  of  the  body. 
The  solid  food  of  a  mixed  diet  has  been  shown  above  to  contain  on  the 
average  50  or  60  per  cent  of  water,  so  that  about  25  ounces  of  water 
are  taken  into  the  system  daily  as  an  integral  part  of  the  food.  In 
addition,  at  least  55  ounces  or  more  should  be  drunk  either  as  plain 
water  or  in  various  beverages. 

Another  way  of  stating  the  above  facts  is  that  the  average  quan- 
tity of  solid  food  (not  water-free)  which  is  required  by  adults  is  be- 
tween 40  and  45  ounces  per  diem,  and  the  total  amount  of  food,  in- 
cluding all  fluids,  should  be  from  95  to  120  ounces,  of  which  three 
fifths  or  four  fifths  is  composed  of  water,  and  the  remaining  one  or 
two  fifths  of  water-free  substance.  These  estimates  are  only  intended 
for  general  application,  and  there  are  necessarily  many  exceptions. 

The  ratio  of  solid  to  liquid  food  varies  in  health  with  the  greater 
or  less  preponderance  of  fluids,  the  solid  being  more  constant.  It  is 
commonly  nearly  i  to  2,  but  many  persons  reduce  it  to  i  to  1.5,  or 
even  i  to  i. 

Muscular  exertion  demands  an  increase  in  both  solid  and  fluid 
food,  but  the  former  is  more  essential  than  the  latter,  if  the  exertion 
be  prolonged. 

When  a  man  does  increasing  work,  unless  his  food  be  proportion- 
ately increased,  he  begins  to  consume  his  own  tissues  until  their  loss 
so  weakens  him  that  he  is  obliged  to  desist  from  a  part,  at  least,  of 
his  labour.     Should  the  disproportion  between  output  and  income 


FOOD   CONCENTRATION.-CONDENSED   FOODS. 


271 


continue,  he  becomes  so  enfeebled  as  to  be  liable  to  the  inroads  of 
disease  in  various  forms — especially  to  the  influences  of  cold  and  of 
zymotic  diseases. 

It  is  estimated  that  in  each  twenty-four  hours  a  man  of  normal 
health  and  physique  absorbs,  including  the  respiratory  oxygen  and 
water,  about  7.25  pounds  of  material,  which  he  eliminates  in  a  corre- 
sponding quantity  of  waste,  about  three  fifths  of  which  is  water. 

One  of  the  best  means  of  determining  the  proper  amount  of  food 
to  sustain  a  man  in  good  health  is  derived  from  a  study  of  the  ex- 
periences of  arctic  explorers.  Their  men  are  subjected  to  great 
hardships  and  feats  of  endurance,  as  well  as  to  intense  cold.  From 
the  nature  of  the  expeditions  no  superfluous  food  can  be  carried,  and 
yet  the  chief  factor  in  success  is  the  maintenance  of  good  bodily 
vigour.  For  these  reasons  the  rations  for  arctic  travellers  have 
been  most  carefully  established,  and  a  brief  review  of  them  will 
throw  much  light  upon  this  interesting  subject. 

The  Peary  expedition  to  the  north  pole  in  1887  used  19  ounces  of 
solid  food  as  the  ration  for  the  sledging  expedition,  but  this  soon 
proved  to  be  inadequate  in  the  cold  of  the  arctic  regions.  Dr.  Ray 
used  29  ounces,  which  also  proved  insufficient,  and  later  34  ounces  of 
solid  food.  Various  other  expeditions  have  used  32  ounces  of  solid 
food,  consisting  wholly  of  pemmican,  which  has  been  sufficient. 

Molintock,  another  arctic  sledge  traveller,  used  40  to  48  ounces 
of  food  daily.  Captain  Neary's  expedition  used  38  ounces  of  solid 
food,  proportioned  as  follows:  Meat,  20  ounces;  biscuits,  14  ounces; 
potatoes,  2  ounces ;  sugar,  2  ounces.  To  this  were  added  chocolate, 
I  ounce;  rum,  2  ounces;  and  1.5  ounce  each  of  tea  and  tobacco 
with  condiments,  making  in  all  44  ounces  of  supplies. 

De  Long  quotes  from  the  physician  to  his  arctic  expedition  that 
"alcohol  proves  a  great  advantage,  keeps  off  the  craving  for  food, 
preventing  gnawing  at  the  stomach,  and  has  kept  up  the  strength  of 
the  men  as  given — 3  ounces  per  day."     (This  was  during  starvation.) 

While  performing  active  exercise  in  the  cold  a  diet  of  1.5  pound 
of  stewed  deer's  meat  was  found  wholly  inadequate  to  prevent  severe 
hunger,  but  1.5  pound  of  pemmican  per  diem,  with  one  half  ounce  of 
tea  and  one  half  .ounce  of  Liebig's  extract  of  meat,  supported  life 
comfortably  for  some  time.  On  leaving  the  ship  behind  and  starting 
on  their  long  sledge  expedition,  the  following  daily  ration  was  al- 
lowed each  man  by  Lieutenant  De  Long : 

Breakfast. 

Pemmican 4  ounces. 

Ham I  ounce. 

Bread 3  "  pieces." 

Coffee 2  ounces. 

Sugar I  ounce. 

20 


272  FOOD   PREPARATION   AND   PRESERVATION. 

Dinner. 

Pemmican 8  ounces. 

Liebig's  extract i  ounce. 

Tea i     " 

Sugar f     " 

Supper. 

Pemmican 4  ounces. 

Tongue i  ounce. 

Tea i    " 

Sugar 1^     " 

Lime  juice i     " 

Bread 4  ounces. 

While  held  fast  in  the  ice,  and  still  on  the  steamer,  the  average  al- 
lowance of  food  per  day  was  about  four  pounds,  but  some  complained 
of  being  hungry  on  this  ration.  Several  men  suffered  s.everely  from 
lead  poisoning  from  the  solder  used  in  canning  tomatoes,  traces  of 
lead  being  found  on  examining  the  contents  of  the  can.  The  acid  of 
the  tomato  acts  upon  the  solder,  forming  a  soluble  lead  salt.  The 
cans,  however,  had  been  kept  for  a  period  of  two  years  before  their 
contents  were  eaten  (De  Long).     (See  Canning,  page  257.) 

In  the  voyage  of  the  Jeannette  to  the  arctic  zone  in  the  polar 
expedition  of  iS/p-'Si  a  very  liberal  diet  was  allowed  the  sailors  on 
entering  the  arctic  regions,  the  average  quantity  of  food  allotted  per 
man  />er  diem  being  a  ration  of  5.5  pounds.  Meat  was  furnished 
three  times  a  day.  Fat  was  supplied  in  the  form  of  pork  and  butter, 
and  bread  and  potatoes  made  the  bulk  of  the  starchy  diet,  constitut- 
ing about  two  thirds  of  the  whole  amount  of  food.  The  diet  at  first 
included  large  quantities  of  condensed  milk,  butter,  eggs,  oatmeal, 
cheese,  and  macaroni,  together  with  a  great  variety  of  canned  fruits 
and  vegetables  and  dried  fruits,  such  as  apples,  peaches,  dates,  figs, 
prunes,  and  raisins. 

In  Lieutenant  A.  W.  Greely's  account  of  the  expedition  (Three 
Years  of  Arctic  Service)  he  says :  "  The  amount  of  food  per  man  each 
day  actually  eaten  in  over  two  years  at  Fort  Conger  was  as  follows: 

Meat 26.8  ounces. 

Canned  vegetables 10. o      " 

Sugar  and  sirup 5.3      " 

Farinaceous  articles 13.6      " 

Canned  fruits 4.7      " 

Dried  fruits,  preserves,  fruit,  butter,  and  pickles 2.9      " 

"This  aggregate  of  64.3  ounces  would  doubtless  be  increased 
by  coffee,  chocolate,  tea,  spices,  condiments,  etc.,  to  nearly  seventy 
ounces.  This  amount  may  reasonably  be  assumed  as  the  quantity 
of  food  necessary  for  the  maintenance  of  a  man's  health  in  a  lati- 
tude such  as  Conger  (81°  44'  N.),  where  the  actual  temperature  is 
4°  F.  (20°  C.)."     He  adds  that  tomatoes  proved  to  be  the  most  serv- 


FOOD    CONCENTRATION.— CONDENSED   FOODS.  273 

iceable  vegetable,  and  apples  and  peaches  the  best  fruits.  The  bev- 
erages consisted  of  coffee,  tea,  chocolate,  cider,  and  a  small  quantity 
of  rum,  the  latter  averaging  two  gills  weekly  for  each  man,  which  he 
regarded  as  beneficial  from  the  effect  it  had  upon  the  cheerfulness 
and  good  humour  of  the  men.  Meat  in  the  above  table  included  fat, 
in  the  shape  of  pemmican  (four  ounces),  butter,  lard,  pork,  and  bacon. 
The  hours  for  meals  were  as  follows:  Breakfast,  7  a.  m.  Dinner, 
4  p.  M.,  and  two  lunches.  The  latter  consisted  of  hard  bread  and 
butter,  tea  and  coffee.     The  typical  vienu  was  as  follows: 

Breakfast. — Corned  beef,  oatmeal,  fresh  bread,  chocolate,  or 
coffee. 

Dinner. — Vegetable  soup,  baked  pork  and  beans,  corned  bread, 
stewed  peaches,  and  coffee. 

On  sledging  expeditions  it  was  important  to  reduce  the  weight 
and  bulk  of  the  food  to  a  minimum;  accordingly  in  the  Greely  ex- 
pedition of  1882  the  daily  allowance  for  sledging  expeditions  was 
thirty-nine  ounces,  to  which  was  added  an  ounce  of  lime  juice.  The 
lime  juice  was  carried  frozen  in  small  squares,  in  which  form  it 
proved  refreshing  and  invigorating  to  the  exhausted  men.  This 
constituted  the  ration  of  the  first  year,  1882,     Greely  writes: 

"On  the  above  ration  of  1882  parties  kept  the  field  for  forty 
days  in  a  mean  temperature  below  zero  17.8°  C,  and  returned  in 
health  and  strength." 

In  1883  the  experience  of  the  previous  year  led  him  to  modify 
the  ration  by  replacing  part  of  the  bread  with  butter  and  meat. 
This  modified  ration  consisted  of — 

Meat .' 22  ounces. 

Butter 2      " 

Vegetables 4 

Bread lo      " 

Sugar 2 

Milk i  ounce. 

Tea  or  chocolate i 

Salt \      " 

Pepper sff 

with  an  allowance  of  six  ounces  of  alcohol  for  cooking  the  food  of 
a  party  of  three  or  four  people;  therefore  the  ration  contained 
40.5  ounces  besides  beverages.  Greely  says  again  :  "  Three  fourths 
of  the  ration  were  about  equal  quantities  of  pemmican,  bacon,  and 
frozen  musk  meat,  while  the  balance  was  made  up  of  canned  sau- 
sages and  corned  beef  in  about  equal  quantities  "  (Three  Years  of 
Arctic  Servicer,  vol.  i,  pp.  202,  203).  He  suggests  as  a  still  further 
improvement  that  the  vegetable  ration  should  consist  of  three  ounces 
of  preserved  potatoes,  the  remaining  ounce  being  replaced  by  half 
an  ounce  each  of  milk  and  extract  of  beef  tea,  which  is  the  best 
drink  for  the  arctic  regions.     It  should  be  chiefly  used  in  the  field  in 


274  FOOD   PREPARATION   AND   PRESERVATION. 

the  form  of  an  extract.  A  little  coffee  is  preferable  to  chocolate. 
The  latter  was  found  to  induce  thirst  during  the  day.  Tea  should 
be  compressed  or  used  as  an  extract.  Curry  paste  and  other  power- 
ful condiments  were  also  found  serviceable.  Alcohol  was  not  con- 
sidered necessary  as  a  food. 

During  the  third  winter  of  his  arctic  expedition,  from  November 
I,  1883,  to  June  23,  1884,  Greely's  per  capita  ration  for  his  entire 
party  was : 

Butter 0.5  ounce. 

Lard o. 26     " 

Rice 0.1       " 


Raisins o.  16 

Tea,  compressed 0.3 

Extract  of  coffee 0.44 

Extract  of  chocolate 0.3 

Milk 0.2 

Mulberries 0.2 


Meat 4.0  ounces. 

Beef  extract 0.26  ounce, 

Evaporated  potato 0.4       " 

Soup 0.6       " 

Tomatoes 0.3       " 

Peas 0.2       " 

Corn 0.2       " 

Carrots o.  i       " 

Bread 6.0  ounces. 

Dog  biscuit 0.8  ounce. 

The  usual  estimate  for  the  total  quantity  of  all  food  material,  in- 
cluding solids,  water,  and  respiratory  oxygen  as  well,  which  is  con- 
sumed by  a  healthy  adult  male  per  annum  is  one  and  a  half  ton. 
Men  eat  about  two  thirds  of  all  the  meat,  and  women  one  third. 
Men  consume  about  four  fifths  of  all  the  alcoholic  beverages,  and 
women  one  fifth.     The  latter  consume  much  more  tea  than  men. 

Soyer  has  computed  some  curious  tables  of  the  total  quantity  of 
different  foods  consumed  by  a  single  individual  during  his  lifetime. 
He  estimates  that  a  man  during  sixty  years  of  life  after  early  child- 
hood eats  Z2>^ln  tons  of  meat,  vegetables,  and  farinaceous  food,  and 
that  an  ordinary  man  by  the  time  he  has  attained  to  seventy  years  has 
consumed  30  oxen,  200  sheep,  100  calves,  200  lambs,  50  pigs,  1,200 
fowls,  300  turkeys,  24,000  eggs,  4.5  tons  of  bread,  and  3,000  gallons 
of  tea  and  coffee. 

Starvation  and  Inanition. 

Starvation  is  a  term  which  technically  applies  rather  to  the  lack 
of  sufficient  food  for  the  maintenance  of  the  body,  while  inanition 
means  the  lack  of  assimilation  of  food  by  the  tissues.  Where  there 
is  defective  absorption,  food  may  be  furnished  to  the  system  in 
abundant  quantity,  but  inanition  results  from  lack  of  ability  to  ab- 
sorb and  develop  force  and  nutriment  from  it.  The  interval  through 
which  different  individuals  can  subsist  without  food  depends  upon  : 
I,  External  conditions  of  temperature  and  moisture ;  2,  the  amount 
of  work  being  performed;  and  3,  the  existing  condition  of  the  body. 

I.  The  maintenance  of  a  uniform  warm  external  temperature 
prolongs  the  period  through  which  man  can  endure  abstinence  from 
food.     Exposure  to  cold  accelerates  starvation  symptoms  by  reduc- 


FOOD  CONCENTRATION.— CONDENSED  FOODS. 


275 


ing  the  vitality  of  the  body  and  the  resistance  of  the  system. 
Moisture  in  the  air,  by  preventing  evaporation  from  the  surface  of 
the  body,  prolongs  the  period  of  starvation  which  can  be  endured. 

2.  Persons  who  refrain  completely  from  exercise  can  live  far 
longer  without  food  than  when  undergoing  active  work.  Self-for- 
getfulness  in  times  of  famine,  by  diverting  the  mind  from  the  suf- 
ferings of  the  body,  tends  to  prolong  life. 

3.  Well-nourishjed  persons  can  endure  longer  intervals  of  absti- 
nence from  food  than  the  weak  or  diseased.  The  distress  of  deliri- 
ous or  apparently  insensible  persons  may  be  augmented  by  lack  of 
sufficient  food.  Sex  has  no  influence  with  the  effects  of  starvation, 
but  they  are  most  keenly  felt  at  the  extremes  of  age,  by  young  chil- 
dren, and  senile  subjects. 

Those  who  have  the  most  fat  stored  in  their  tissues  call  upon  this 
supply  to  maintain  the  energy  of  the  body  in  the  absence  of  food,  and, 
having  a  larger  supply  than  thin  or  emaciated  persons,  they  can  en- 
dure starvation  much  longer,  although  they  may  complain  more  bit- 
terly of  the  pangs  of  hunger  than  invalids,  who  are  accustomed  to  a 
low  diet.  Chossat's  experiments  with  starving  animals  proved  that 
while  they  lost  40  per  cent  of  body  weight,  the  loss  of  fat  alone 
reached  90  per  cent,  being  greatly  in  excess  of  that  of  any  other 
.substance.  Anselmier  fed  starved  dogs  upon  their  own  blood,  and 
succeeded  in  thus  prolonging  their  lives  for  three  or  four  days  be- 
yond the  usual  limit,  and  life  lasted  until  60  instead  of  40  per  cent 
of  their  body  weight  had  been  lost. 

When  food  is  wholly  withheld,  life  cannot  be  prolonged  beyond 
six  to  ten  days  in  the  majority  of  instances.  During  the  winter  of 
i876-'77  an  accident  occurred  in  a  colliery  in  South  Wales  by  which 
four  men  and  a  boy  became  imprisoned  for  ten  days  without  food. 
At  the  expiration  of  this  period  they  were  found  alive,  and,  although 
very  feeble,  they  were  able  to  walk  when  released.  They  had  had 
a  supply  of  water,  and  the  atmosphere  in  which  they  were  confined 
was  moist.  At  a  second  recent  colliery  accident  in  Wales  a  number 
of  men  were  confined  in  a  mine  for  six  days  without  food,  and, 
although  their  sufferings  were  extreme,  nearly  all  were  able  to  walk 
out  on  being  rescued. 

The  lack  of  food  may  be  endured  with  far  less  torture  if  water  is 
applied  in  abundance  to  the  system.  When  water  is  withheld  in 
addition  the  body  loses  weight  much  more  rapidly,  the  tissues  be- 
come dry,  the  thirst  excessive,  the  secretions  are  suppressed,  and  the 
suffering  is  greatly  intensified. 

VOLUNTARY   FASTING. 
Of  late  years  several  persons  have  attempted  prolonged  feats  of 
starvation,  tempted  by  love  of  notoriety  or  desire  of  gain,  by  ex- 


276  FOOD   PREPARATION   AND   PRESERVATION.  " 

hibiting  themselves  for  the  gratification  of  public  curiosity.  In  sev- 
eral instances  they  have  been  carefully  watched  by  medical  experts 
and  there  is  every  reason  to  believe  that  the  fast  has  been  conducted 
with  honesty.  In  at  least  two  of  these  authenticated  instances,, 
those  of  Tanner  and  Succi,  the  complete  starvation  period  has  been 
prolonged  for  over  forty  days.  In  both  cases  fluids  were  allowed, 
and  one  of  the  men  relieved  intense  epigastric  pain  and  food  craving 
by  condensed  medication.  % 

Succi  was  an  Italian  who,  in  1890,  undertook  an  absolute  fast  of 
forty-five  days,  during  which  period  he  lost  42'/^  pounds  and  drank 
1,154  ounces  of  water,  or  an  average  of  about  2^^!^  ounces  per  diem. 
This  he  took  in  the  forms  of  plain  water,  mineral  water,  and  ice. 
He  became  alarmingly  reduced  during  the  fast,  but  even  on  the 
last  day  had  strength  to  walk  about  the  room.  He  resumed  eat- 
ing by  first  taking  cocoa,  and  subsequently  bouillon  and  other  light 
articles,  and  made  a  complete  recovery.  His  mind  remained  clear 
throughout.  He  took  occasional  doses  of  a  few  drops  of  an  elixir 
supposed  to  contain  opium. 

There  have  been  a  number  of  cases  from  time  to  time  recorded 
of  "  fasting  girls."  They  are  usually  of  nervous  hysterical  tempera- 
ment. On  reaching  the  age  of  puberty  they  become  dyspeptic  and 
grow  shy  and  disinclined  to  eat  what  is  good  for  them,  although 
they  may  gratify  abnormal  cravings  surreptitiously.  They  are  very 
apt  to  be  at  the  same  time  strongly  impressed  by  religious  beliefs, 
and  in  their  disordered  mental  condition  to  acquire  the  delusion 
that  it  is  sinful  to  eat.  This  delusion  becomes  fixed,  and  they  then 
are  regarded  as  "  freaks  "  and  achieve  much  newspaper  advertising. 
They  should  be  treated  as  ordinary  cases  of  hysteria  simply,  and  be 
removed  from  oversympathetic  friends  and  dealt  with  kindly  but 
firmly.  Hydrotherapy  yields  excellent  results,  and  even  a  good 
spanking  may  not  be  amiss  in  awaking  the  patient  to  a  realising 
sense  of  her  errors.  The  claim  sometimes  made  in  such  cases  as 
those  just  described,  that  they  lose  no  weight,  is  nonsensical,  for 
the  body  must  diminish  in  weight  continually  by  evaporation  of 
water  from  the  lungs  and  skin  and  its  passage  from  the  kidneys  and 
by  the  exhalation  of  carbon.  Edward  Smith  estimates  that  the 
quantity  of  carbon  exhaled  in  one  day  of  fasting  is  equivalent  to 
that  contained  in  twenty  ounces  of  bread. 

When  either  voluntary  or  forced  starvation  takes  place  very 
gradually,  especially  in  elderly  people,  their  systems  become  slowly 
accustomed  to  very  small  quantities  of  food. 

Luigi  Cornaro  was  a  Venetian  gentleman  who  advocated  a  very 
abstemious  diet,  and  whose  own  case  is  often  cited  in  illustration  of 
the  smallest  quantity  of  food  which  may  support  life.  He  was  born 
in  1463 ;  after  a  reckless  and  intemperate  youth  he  reformed,  and 


FOOD   CONCENTRATION.— CONDENSED   FOODS. 


277 


by  careful  dieting  prolonged  his  life  to  one  hundred  and  three  years. 
He  published  a  Treatise  on  a  Temperate  Life,  and  for  the  last 
forty-eight  years  of  his  own  existence  he  subsisted  on  a  daily  allow- 
ance of  twelve  ounces  of  vegetable  food  with  fourteen  ounces  of 
light  wine.  He  occasionally  ate  eggs,  but  rarely  took  any  other 
form  of  animal  food. 

There  is  much  wisdom  in  some  of  his  doctrines,  but,  unfortu- 
nately, no  one  else  who  has  attempted  to  practise  his  rules  has  met 
with  similar  success  in  prolonging  life.  The  majority  of  mankind 
would  undoubtedly  prefer  to  live  fewer  years  for  the  pleasure  of 
being  less  abstemious. 

Periods  of  voluntary  fasting  of  greater  or  less  duration  are  rec- 
ommended and  practised  by  devotees  of  many  religious  sects. 
Such  fasting  was  formerly  carried  to  a  greater  extent  by  ascetics 
than  at  the  present  time.  As  a  means  of  mental  discipline  or  culti- 
vation of  will  power,  fasting  may  in  some  instances  be  defended, 
but  fasting  "to  be  useful  must  be  voluntary  "  (Chambers),  otherwise 
it  is  apt  to  cause  irritability  of  temper,  and  it  may  even  lead  to  de- 
ception to  obtain  food.  Such  fasting  may  be  carried  to  an  excessive 
and  injurious  degree  unless  it  be  definitely  limited  and  supervised. 
It  is  more  powerful  in  its  effect,  moreover,  if  it  is  but  seldom  under- 
taken. If  a  man  so  reduces  himself  by  fasting  that  he  cannot  use 
his  intellectual  faculties  with  accustomed  vigour  he  may  be  sure  that 
he  is  doing  himself  injury.  Better  than  complete  fasting  for  pur- 
poses of  mental  discipline  or  religious  motives  is  the  temporary 
elimination  from  the  diet  of  accustomed  luxuries,  or  giving  up  such 
articles  of  daily  use  as  butter,  sugar,  salt,  wine,  tobacco,  etc.  This,  in 
fact,  is  a  custom  practised  by  many  persons  during  the  Lenten  season. 

The  day  has  long  since  passed  when  fasting  can  be  regarded  as 
favouring  either  clearness  of  intellect,  muscular  strength,  or  en- 
durance, and,  as  Gerland  has  said,  "  the  ethnologist  can  trace  the 
physical  and  mental  decay  of  whole  nations  to  a  long  course  of  insuf- 
ficient food." 

Dr.  Denis,  of  Brussels  University,  presented  an  interesting  report 
at  the  International  Congress  of  Anthropology  for  1892,  showing 
striking  parallelism  in  the  curves  of  famine  and  crime,  and  of  mar- 
riages as  inversely  related  to  the  price  of  wheat. 

Symptoms. — The  symptoms  which  result  from  complete  star- 
vation are  characteristic.  If  food  is  suddenly  withheld,  the  sensation 
of  hunger  gradually  increases  at  first,  becomes  extreme,  lasts  for  two 
or  three  days,  and  slowly  disappears.  It  is  accompanied  by  a  gnaw- 
ing pain  in  the  epigastrium,  which  is  relieved  on  pressure.  The  pain 
may  disappear  with  the  hunger,  but  it  is  followed  by  a  sensation  of 
extreme  weakness  or  faintness,  which  is  both  local  in  the  stomach 
and  general  throughout  the  body. 


27? 


FOOD   PREPARATION   AND    PRESERVATION. 


When  food  is  gradually  withheld,  urgent  hunger  may  not  be  felt 
at  all,  but  the  longer  and  more  severe  the  fast,  the  more  difficult 
does  digestion  become.  The  circulation  grows  feeble,  the  heart  ac- 
tion rapid,  the  respiration  shallow  and  possibly  slow  and  irregular^ 
There  is  apt  to  be  some  thirst,  even  though  water  be  supplied.  If  it 
be  withheld,  the  torture  becomes  unbearable.  Constipation  may  be 
succeeded  by  diarrhoea,  but  it  more  often  remains  complete.  The 
facies  are  typical,  the  expression  is  anxious  and  staring,  the  orbital 
fat  disappears,  and  the  eyes  are  greatly  sunken  and  finally  become 
glassy.  Corneal  ulceration  may  be  present.  General  bodily  ema- 
ciation ensues,  the  muscles  are  reduced  in  size  and  soft,  the  skin 
becomes  pale,  loose,  and,  from  change  in  the  secretion  of  perspiration, 
emits  a  peculiar  foetor  and  acquires  a  clay-like  colour.  The  feet  and 
ankles  may  swell,  owing  to  the  enfeebled  circulation. 

The  victims  become  so  ravenous  that  all  sense  of  taste  gives  place 
to  the  intense  hunger.  Upon  one  of  the  recent  unfortunate  arctic 
expeditions,  on  one  occasion,  the  tea  being  accidentally  omitted  from 
the  kettle,  dirty  water  was  drunk  by  the  starving  men  without  rec- 
ognising the  difference.  The  secretions  are  altered,  and  become 
inactive.  The  total  volume  of  blood  is  diminished,  and  it  becomes 
ansemic. 

The  body  temperature  begins  to  fall  in  the  first  day  of  the  period 
of  starvation,  and  continues  falling,  so  that  a  loss  of  ten  or  more 
degrees  below  the  normal  of  98. 6*^  F.  may  occur. 

In  extreme  cases  muscular  action  is  no  longer  possible;  there  are 
vertigo  and  faintness  on  raising  the  head,  the  voice  is  lost,  and  grad- 
ually the  nervous  system  succumbs  to  languor  and  general  pros- 
tration ;  the  mind  becomes  more  and  more  dull,  listless,  and  even 
idiotic,  the  victim  being  unable  to  describe  his  condition  or  express 
his  wants.  He  may  have  hallucinations,  insomnia,  and  dreams,  in 
which  are  often  pictured  scenes  of  plenty. 

The  sufferings  produced  by  slow  starvation  distract  the  mind 
and  render  connected  thought  difficult.  If  long  continued,  the  mind 
becomes  unbalanced,  and  men  who  have  been  shipwrecked  and  left 
to  wander  in  the  open  sea  in  rowboats  for  a  long  time  without  food 
usually  become  delirious,  or  even  maniacal,  within  four  or  five  days. 

In  1874  three  men  and  two  boys  were  starved  for  twenty-two 
days  in  an  open  boat.  They  had  at  first  ten  days'  provisions,  and 
subsequently  nothing  but  old  boots  and  jellyfish,  and  they  fought 
violently  with  each  other  in  the  delirium  which  ensued  (Chambers). 

During  prolonged  starvation  the  most  important  organs  of  the 
body  are  nourished  at  the  expense  of  others,  especially  of  the  skeletal 
muscles.  For  example,  in  an  animal  starved  for  thirteen  consecutive 
days  it  was  found  that  while  the  muscles  lost  30  per  cent  in  weight, 
the  brain  lost  but  3  per  cent  and  the  heart  but  2.5  per  cent. 


FOOD  CONCENTRATION.— CONDENSED  FOODS. 


279 


The  ultimate  effects  of  starvation  are  identical  whether  the  pro- 
cess be  gradual  or  rapid,  occupying  days  or  years,  and  death  results 
when  the  body  has  lost  six  tenths  of  its  weight.  It  may  occur  while 
the  victim  is  in  stupor  or  coma  from  cardiac  failure  or,  possibly,  in 
convulsion.  The  actual  cause  of  death  has  by  many  been  attributed 
to  the  loss  of  body  heat.  While  this  is  undoubtedly  a  contributing 
factor,  it  is  more  reasonable  to  suppose  that  it  is  due  to  the  general 
inanition  of  the  muscles  and  nerves  and  the  progressive  enfeeble- 
ment  of  the  heart  action.  The  heart  muscle  not  infrequently  will 
be  found  to  have  undergone  fatty  degeneration.  It  is,  however,  true 
that  in  animals  kept  warm  by  artificial  means  the  advent  of  death 
from  starvation  may  be  considerably  postponed. 

While  undergoing  starvation  the  blood  is  reduced  in  volume  pro- 
portionately with  the  loss  in  body  weight,  but  it  nevertheless  main- 
tains the  balance  of  its  normal  average  composition  (Panum  and 
Voit.) 

Hunger  is  not  always  a  reliable  guide  as  to  the  need  of  the  sys- 
tem for  food.  Some  dyspeptics  are  always  hungry  and  eat  moje 
than  they  can  digest.  Hunger  begets  a  habit  of  too  rapid  eating, 
and  more  food  may  be  taken  than  is  necessary,  because  it  has  not 
had  time  to  be  absorbed  and  reach  the  tissues  before  the  meal  is 
over.  Moreover,  hunger  may  be  temporarily  appeased  by  eating 
other  substances  than  food,  like  bits  of  old  leather,  for  example, 
which  appear  to  act  mechanically  in  the  stomach.  For  this  pur- 
pose men  rendered  insane  by  hunger  will  sometimes  swallow  all 
manner  of  useless  and  harmful  substances,  such  as  buttons,  pieces 
of  metal,  pebbles,  etc. 

No  more  graphic  and  pathetic  account  of  the  miseries  of  star- 
vation exists  than  is  found  in  the  journal  of  Lieutenant  De  Long, 
commanding  the  expedition  of  the  Jeannette,  which  visited  the  arctic 
regions  in  i879-'8i  (The  Voyage  of  the  Jeannette,  Journals  of  George 
W.  De  Long,  1883).  After  leaving  their  sinking  vessel  the  members 
of  the  expedition  were  exposed,  at  first  in  open  boats,  and  later  in 
their  long  sledge  journey,  to  the  most  exhausting  work  and  to 
intense  suffering  from  cold  and  wet.  They  frequently  dragged 
their  sleds  in  severe  storms  for  ten  or  twelve  miles  a  day,  while 
subsisting  solely  upon  half  a  pound  of  stewed  deer  meat,  with  a 
little  tea  three  times  a  day.  This  food  being  exhausted,  they  were 
obliged  to  consume  the  meat  of  their  last  remaining  dog,  which  they 
ate  fried.  They  subsisted  upon  this  food  exclusively  for  four  days 
longer,  having  an  allowance  of  but  half  a  pound  a  day,  and  finally 
their  last  journey  of  twenty-five  miles  was  performed  with  no  other 
nourishment  than  a  few  ounces  of  alcohol  and  an  infusion  made 
from  some  old  tea  leaves.  During  this  time  their  intense  suffering 
from  hunger  was   partially  alleviated  by   chewing    scraps  of    deer 


2^0        FOOD  PREPARATION  AND  PRESERVATION. 

skin,  which,  from  its  bulk   in    the  stomach,  seemed  to  afford  slight 

relief. 

The  alcohol  being  exhausted,  they  lived  for  another  day  upon  a 
teaspoonful  of  olive  oil,  with  a  breakfast  composed  of  an  infusion  . 
made  from  the  arctic  willow  (containing  really  no  nourishment) 
and  "two  old  boots."  After  this  the  men,  becoming  weaker  and 
weaker,  were  unable  to  proceed  farther  on  their  journey,  being 
driven  back  by  intense  cold  and  the  difificulty  of  crossing  the  par- 
tially unfrozen  rivers.  Their  feebleness  gradually  overcame  them, 
until  one  by  one  they  died  of  inanition.  Four  men  survived  for  six- 
teen days  upon  absolutely  no  food  whatever,  and  possibly  their 
sufferings  were  even  further  prolonged,  but  the  journal  of  their 
gallant  and  heroic  commander  ceased  at  this  point,  for  he,  too, 
died. 

In  the  starvation  which  overtook  the  members  of  the  Greely 
party  on  the  Lady  Franklin  Bay  Expedition,  and  caused  the  death 
of  a  large  number  of  the  company,  attempts  were  made,  as  in  the 
case  of  the  Jeannette  expedition,  to  relieve  the  agonies  of  hunger  by 
filling  the  stomach  with  indigestible  material  of  various  kinds.  The 
skin  sleeping  bags  were  roasted  or  boiled  and  eaten,  and  even  oil- 
tanned  skin  was  consumed,  while  the  sufferings  of  the  men  were 
aggravated  by  the  presence  of  game  in  sight  but  out  of  reach.  A 
few  shrimp  and  lichens  were  obtained  and  stewed  with  seal  skin.  At 
this  time,  although  it  was  summer,  the  temperature  was  occasionally 
below  the  freezing  point,  but  during  part  of  the  two  years  spent 
in  the  vicinity  of  Fort  Conger  it  was  sometimes  —40°  or  even  —60°  F. 

During  the  siege  of  Paris  in  187 1,  when  thousands  of  the  inhabit- 
ants were  reduced  to  starvation,  it  was  found  that  a  diet  which  was 
barely  sufficient  to  support  life  consisted  of  ten  ounces  of  bread 
with  one  ounce  of  meat. 

In  prisons  the  diet  limit  has  often  been  reduced  too  low.  It 
may  be  sufficient  to  maintain  life,  but  if  hard  labour  be  inflicted, 
weakness,  sickness,  and  death  will  inevitably  follow.  In  an  over- 
crowded prison  a  daily  ration  of  twenty-eight  ounces  of  unbolted 
meal  and  five  ounces  of  bacon  has  been  known  to  cause  death  by 
slow  starvation.  As  a  means  of  discipline  a  starvation  diet  is  some- 
times enforced  in  penal  institutions  for  a  few  days,  and  it  is  usually 
quite  as  efficacious  as  corporal  punishment.  A  diet  which  is  de- 
signed to  effect  its  aim  by  monotony  as  well  as  reduction  in  quan- 
tity, but  without  reaching  the  limit  of  cruelty,  is  the  following, 
which  has  been  used  at  the  United  States  military  prison  at  Fort 
Leavenworth  : 

Breakfast. — Hash  or  stew,  8  ounces;  bread,  7.5  ounces. 

Dinner. — Soup,  8  ounces;  bread,  7.5  ounces. 

After  twenty  continuous  days  of  this  diet  eight  ounces  of  bread 


FOOD  CONCENTRATION.— CONDENSED  FOODS.      28 1 

are  allowed  for  supper.      This  diet   has    been   found   to  make  the 
most  refractory  men  soon  manageable  (See  Diet  in   Prisons). 

Treatment. — The  treatment  of  persons  rescued  from  starvation 
must  be  conducted  with  the  utmost  care.  The  digestive  system  is 
so  enfeebled  that  to  allow  them  to  yield  to  the  cravings  of  returning 
appetite  is  to  insure  immediate  death  by  overburdening  the  stomach 
and  circulation.  The  body  should  be  kept  warm  and  in  absolute 
rest,  and  warm  fluid  nourishment  in  minute  quantities — half  tea- 
spoonful  doses  of  beef  peptones  or  meat  juice — may  be  given  at 
intervals  of  fifteen  minutes  or  half  an  hour.  If  no  vomiting  or  evil 
symptom  results,  small  quantities  of  peptonised  milk  may  be  tried 
at  half-hour  intervals.  Alcoholic  stimulants  in  any  quantity  are  to 
be  avoided,  but  a  few  drops  of  brandy  or  whisky  may  be  given  from 
time  to  time  in  water.  If  the  stomach  is  irritable,  nutrient  enemata 
should  be  employed.  The  following  day  the  quantity  of  food  may 
be  slightly  increased,  but  if  emaciation  is  extreme  and  enfeeblement 
is  pronounced,  the  patient  must  be  kept  upon  a  fluid  diet  for  ten 
days  or  more.  Easily  digested  forms  of  starchy  food  may  then  be 
added,  such  as  dry  bread,  arrowroot,  gruel,  and  the  like. 

FAMINE. 

When  starvation  occurs  upon  a  large  scale,  affecting  a  community 
with  famine,  pestilence  is  sure  to  accompany  it.  Disease  has  always 
been  rampant  in  Ireland  when  the  potato  crops  have  failed,  and  in 
India  when  the  grain  supply  has  given  out.  Much  of  the  illness 
which  occurred  in  the  early  history  of  the  Crimea  was  due  to  insuffi- 
cient food,  and  in  the  Middle  Ages  the  ravages  of  pestilential  dis- 
eases, such  as  typhus,  blackpox,  the  plague,  etc.,  were  always  worst 
in  times  of  general  starvation.  The  history  of  epochs  of  famine  in 
siege  or  otherwise  is  always  accompanied  by  outbreaks  of  violence, 
for  hunger  begets  ill-temper,  vice,  and  crime.  This  has  occurred  of 
late  years,  notably  in  Athens,  Florence,  and  London,  and  in  Paris 
during  the  Commune. 

Nothing  predisposes  man  so  much  to  all  forms  of  infectious  dis- 
ease as  starvation  and  inanition.  This  is  so  v/ell  known  that  phy- 
sicians and  nurses  in  charge  of  contagious  cases  are  particularly 
cautioned  to  eat  well  and  not  expose  themselves  to  infection  while 
suffering  from  fatigue  and  lack  of  food. 

Improperly  Balanced  Ingredients  of  Diet. 

Improper  diet  is  often  quite  as  injurious  as  slov/  starvation,  for  a 
person  who  eats  a  large  bulk  of  food  of  one  class,  to  the  exclusion 
of  other  classes,  may  delude  himself  by  thinking  that  he  is  taking 
nourishment  enough  on  account  of  the  degree  of  satiety  which  he 


282 


FOOD  PREPARATION  AND  PRESERVATION. 


derives  from  his  diet.  "  The  outward  appearance  of  such  persons  is 
to  a  certain  extent  characteristic,  marked  generally  by  a  pale  and 
puffy  aspect,  due  partly  to  a  general  excess  of  water  in  the  tissues 
and  partly  to  an  abnormal  deposition  of  fat  "  (Bauer).  The  evil 
result  of  such  diet  is  very  apparent  among  infants  and  growing 
children  who  have  been  fed  upon  a  large  bulk  of  farinaceous  food  to 
the  exclusion  of  milk,  meat  juice,  etc.,  and  in  them  the  foundation 
may  be  laid  for  the  development  of  scurvy,  or  scrofula,  or  tuberculo- 
sis, and  sometimes  also  the  stomach  and  bowels  become  permanently 
distended  (see  Diet  for  Infants  and  Children,  pages  718  and  732). 

The  effects  above  described  are  commonly  produced  by  excessive 
ingestion  of  starchy  and  saccharine  foods  to  the  exclusion  of  proteids, 
and,  on  account  of  the  cheaper  cost,  the  children  of  the  poor  are 
more  apt  to  be  injured  in  this  manner  than  the  rich,  among  whom 
the  opposite  diet — an  excess  of  nitrogenous  aliments — is  more  com- 
mon. The  latter  sometimes  gives  rise  to  circulatory  disturbances, 
overworks  the  kidnfeys,  and  produces  nervous  irritability. 

It  has  often  been  observed  by  dietists  that  proportionately  more 
fat  is  consumed  in  the  United  States  than  in  Europe,  and  some  are 
inclined  to  attribute  to  this  form  of  food  some  influence  upon  the 
greater  activity  which  characterises  Americans.  It  is  extremely 
doubtful  whether  this  has  as  much  to  do  with  it  as  climatic  and 
other  conditions  of  environment. 

Taken  by  themselves,  carbohydrates  have  little  or  no  effect  in 
deferring  death  from  starvation,  but  with  albuminates  they  act  as 
tissue  sparers  (see  Force-producing  Value  of  Foods,  page  16). 

Mrs.  Richards  gives  the  following  useful  comparisons  of  food 
composition,  showing  particularly  the  inefficiency  of  fluid  diets  other 
than  milk  to  support  life  : 


Three  quarts  of  milk 

Three  quarts  of  beef  broth  or  consommi . ... 

Soup  of  Munich  Hospital 

Rations  recommended  in  certain  invalid  re 

ceipt  books 

Rations  recommended  in  another  receipt  book 
Prausnitz's  estimate  of  normal  ration  for  man 
Prausnitz's    estimate    of    normal    ration    for 

woman 

Estimated  life  ration 

Maximum  work  ration 

Minimum  work  ration 

Common  invalid  ration  too  low  in  proteids  : 
I  pint  beef  juice,  containing  7  per  cent.. . . 
I  pint  whole  milk 

1  quart  flour  gruel,  made  with  whole  milk. 

2  quarts  of  liquid.     Total 


Proteid. 

Fat. 

102.0 

108.0 

123.0 

3-0 

21.6 

21.6 

24-5 

28.5 

66.5 

23.5 

IIO.O 

50.0 

100. 0 

50.0 

75-0 

40.0 

125.0 

125.0 

IIO.O 

90.0 

31.5 

17.0 

18.0 

18.2 

18.2 

66.7 

36.2 

Carbo- 
hydrate. 


132.0 
108.0 

65.6 

83.5 

350-400 

300-350 

325-0 

450.0 

420.0 


22.0 
38.0 


60.0 


Calories. 


I.953-0 
532.0 
730.0 

631.0 
831.0 

2,350.0 
2,100.0 

2,COO.O 
3,500.0 
3,000.0 


129.0 

325.5 

397-9 


852.4 


PART   IV. 
FOODS   REQUIRED   FOR   SPECIAL   CONDITIONS. 


AGE  AND   FOOD. 
INDIVIDUAL   SIZE   AND   FOOD. 
BODY   WEIGHT   AND   FOOD. 
SEX  AND   FOOD. 


DIET  AND   HEREDITY. 
DIET   AND    RACE. 
CLIMATE      AND       SEASON 
FOOD. 


AND 


AGE   AND    FOOD. 

Food   in  Childhood. 

A  CHILD  at  three  or  four  years  of  age  actually  consumes  nearly 
one  fourth  as  much  food  as  it  requires  at  adult  life,  for  during  this 
process  tissue  growth  is  very  rapid,  and  if  the  child  be  in  health, 
the  bodily  activity  is  relatively  very  great.  An  active  child  at 
twelve  or  fifteen  years  of  age  who  is  growing  fast  and  who  is  freely 
exercising  may  require  and  assimilate  as  much  food  as  a  man  past 
middle  age,  and  insufficient  food  and  food  of  defective  quality  and 
composition  work  proportionately  far  more  harm  during  the  grow- 
ing age. 

Inquiries  made  in  this  country  in  regard  to  the  diet  of  older 
children  and  young  adults  demonstrate  that  it  contains  a  proportion- 
ately large  quantity  of  fatty  food — much  more  than  is  customarily 
consumed  in  European  countries.  This  is  in  great  part  owing  to 
the  habit  of  eating  considerable  butter,  which,  generally  speaking, 
the  better  circumstances  of  Americans  enable  them  to  obtain. 

The  following  table  from  the  investigations  of  the  Munich  School 
gives: 

The  Minimum  Amount  of  Food  Necessary  for  Different  Ages. 


Age. 


Infant  unlil  one  and  a  half  year. 
Child  from  six  to  fifteen  years. . 

Man  (moderate  work) 

Woman 

Aged  man 

Aged  woman 


Nitrogenous 
substances. 

Fat. 

Carbohydrates. 

Grammes, 

Grammes, 

Grammes. 

20-36 

30-45 

60-90 

70-SO 

37-50 

250-400 

118 

56 

500 

92 

44 

400 

100 

63 

350 

80 

50 

260 

283 


284  FOODS   REQUIRED   FOR   SPECIAL   CONDITIONS. 

The  special  diet  regulations  for  infancy  and  childhood  are  de- 
scribed at  length  under  the  headings  Diet  in  Infancy  and  Diet  in 
Childhood. 

Food  in  Adult  Life. 

The  nature  and  quality  of  the  diet  appropriate  for  adults  must 
depend  somewhat  upon  individual  constitution,  occupation,  habits  of 
life,  and  to  some  extent  upon  the  climate  in  which  they  live. 

The  full  adult  weight  is  not  usually  attained  before  the  twenty- 
fifth  year,  although  in  some  cases  it  is  reached  earlier.  In  many  in- 
stances adults  after  the  age  of  forty  or  forty-five  years  increase  con- 
siderably in  weight.  In  men  the  bones  continue  to  solidify  until 
about  the  thirtieth  year;  in  women  this  condition  is  usually  reached 
a  few  years  earlier.  When  the  final  growth  of  the  body  and  develop- 
ment of  the  vital  organs  is  completed  the  use  of  food  consists  simply 
in  maintaining  the  proper  equilibrium  of  the  tissues  by  replacing 
waste  with  new  material  and  in  furnishing  fuel  for  the  development 
of  force,  the  food  being  no  longer  required  for  growth.  Many  per- 
sons eat  more  than  is  required  for  these  purposes. 

As  men  advance  in  life,  become  prosperous,  and  acquire  more 
and  more  luxurious  habits  of  living  or  become  absorbed  in  various 
occupations,  they  are  apt  to  take  less  exercise,  while  the  number  of 
luxuries  of  the  table  which  their  means  enable  them  to  command 
constantly  tempt  them  to  indulge  in  food  which  is  not  needed  and 
which  is  imperfectly  consumed  in  the  body. 

Sir  H.  Thompson  writes   (Diet  in  Relation  to  Age  and  Activity) : 

"  More  than  one  half  of  the  disease  which  embitters  the  middle 
and  latter  part  of  life  among  the  middle  and  upper  classes  of  the 
population  is  due  to  avoidable  errors  in  diet." 

It  is  often  difficult  for  a  man  between  the  ages  of  twenty  and 
thirty  years  who  has  led  an  exceptionally  active  and  vigorous  or 
perhaps  even  an  athletic  life  to  realise,  as  he  grows  older  and  passes 
on  towards  forty-five  or  fifty  years  of  age,  that  he  requires  less  food 
to  maintain  his  organic  equilibrium  than  formerly,  and  his  habits  of 
eating  acquired  at  a  more  impressionable  period  of  life  cling  with 
great  pertinacity.  It  may  prove  an  advantage  sometimes  in  such 
cases  to  lessen  the  appetite  for  dinner  by  a  late  lunch,  or  to  try 
other  simple  means  of  restriction. 

These  observations  fail  of  application  to  the  poor,  whose  means 
do  not  allow  them  to  gratify  their  appetites,  and  in  the  case  of  those 
whose  diet  is  established  for  them.  There  is  quite  as  much,  if  not 
more,  ill  arising  from  deficient  feeding  as  from  overfeeding;  in  either 
case  the  difficulty  is  only  made  serious  by  long  continuance,  and 
occasional  great  indulgence  in  overeating  as  in  overdrinking  is 
much  less  productive  of  harm  than  habitual  indiscretions  of  a  less 


AGE   AND   FOOD.  ,28j; 

degree.  So  much  is  due  to  habit  in  the  different  organs  of  the  body 
in  relation  to  food  that  the  stomach  and  intestine  will  usually  reject 
undigested  the  contents  of  an  occasional  excessive  meal,  whereas 
with  habitual  overeating  they  become  accustomed  to  appropriating 
very  large  quantities  of  food,  which  are  absorbed,  but  which  are  not 
eliminated  without  straining  the  excretory  organs,  or  which  may  be 
stored  in  the  body  in  the  form  of  incompletely  oxidised  material, 
which  accumulates  until  the  system  rebels  and  a  violent  bilious 
attack  by  vomiting  and  purging  relieves  the  overburdened  body. 
There  are  persons  who  have  so  little  restraint  over  their  appetites 
that  they  persistently  indulge  themselves  in  this  way. 

Food  in  Old  Age. 

In  old  age  there  are  inevitable  changes  which  slowly  occur  in 
the  circulatory  and  digestive  organs  of  the  body.  Although  the 
general  health  may  .still  be  unimpaired,  the  circulation  is  less  vigor- 
ous, and  the  nervous  system  less  active  to  external  stimulation. 
There  are  degenerations  in  the  secreting  organs  with  a  tendency  to 
deposition  in  the  tissues  of  phosphate  and  carbonate  of  lime,  derived 
from  the  food.  Absorption  is  less  active,  and  there  is  diminished 
adaptability  of  the  whole  system  to  alterations  in  environment,  and 
much  less  ability  to  meet  the  requirements  of  emergencies,  such  as 
sudden  calls  for  the  use  of  muscles  or  mental  strain.  The  muscular 
tone  of  the  intestine  is  apt  to  deteriorate  and  produce  constipation 
and  a  relaxed  condition  resulting  in  its  dilatation.  The  circulation 
through  the  mesenteric  vessels  and  those  of  the  portal  system  be- 
comes inactive,  with  a  consequent  reduction  in  the  rate  of  absorp- 
tion, and  a  diminished  and  altered  gland  secretion  in  the  liver,  pan- 
creas, etc. 

For  these  reasons  the  digestive  powers  are  less  vigorous,  but, 
on  the  other  hand,  there  is  not  so  much  demand  for  fuel  in  the  body 
as  in  earlier  years.  The  vital  processes  conducted  by  the  circula- 
tion, respiration,  and  metabolic  changes  in  the  tissues  are  very  inac- 
tive, and  there  is  a  correspondingly  restricted  expenditure  of  energy. 

Persons  of  very  advanced  age — those  who  are  past  eighty  years 
or  more — can  sometimes  live  comfortably  on  an  astonishingly  small 
quantity  of  food.  J.  Forster  examined  the  food  of  the  inmates  of  an 
institution  for  elderly  widows  and, found  that  many  of  the  old  women 
subsisted  very  comfortably  upon  a  diet  containing,  in  grammes,  al- 
bumin, 67  ;  fat,  38;  and  carbohydrates,  266. 

Much  depends,  however,  upon  the  rapidity  with  which  the  changes 
above  described  have  developed,  and  dietetic  rules  for  such  cases 
are  not  to  be  based  upon  a  definite  period  of  years  so  much  as  upon 
the  degree  of  senility  which  is  present  in  individual  instances. 


286  FOODS   REQUIRED   FOR   SPECIAL   CONDITIONS. 

Sir  H.  Thompson  (Diet  in  Relation  to  Age  and  Activity),  in  com- 
menting upon  the  progressing  diminution  with  advancing  years  of 
physical  energy  and  of  the  power  to  eliminate  waste  material  from 
the  body,  and  the  consequent  harm  of  overeating,  says  that  if  a  man 
past  his  half  century  of  life  "  continues  to  consume  the  same  abun-- 
dant  breakfasts,  substantial  lunches,  and  heavy  dinners  which  at  the 
summit  of  his  power  he  could  dispose  of  almost  with  impunity,  he  will 
in  time  either  certainly  accumulate  fat  or  become  acquainted  with 
gout  or  rheumatism,  or  show  signs  of  unhealthy  deposit  of  some  kind 
in  some  part  of  the  body — processes  which  must  inevitably  empoison, 
undermine,  or  shorten  his  remaining  term  of  life.  .  .  .  The  typical 
man  of  eighty  or  ninety  years  is  lean  and  spare,  and  lives  on  slender 
rations." 

In  the  dietetic  treatment  of  cases  of  advanced  old  age  the  rules 
which  are  naturally  suggested  are  : 

1.  To  diminish  the  total  quantity  of  food  ingested. 

2.  To  give  food  at  frequent  intervals  in  small  amount. 

3.  To  give  only  easily  digestible  food,  which  does  not  produce  too 
large  a  residue  of  waste  matter,  either  in  the  intestinal  canal  or  in 
the  form  of  excrementitious  material  in  the  blood. 

It  is  an  undoubted  fact  that,  having  reached  an  advanced  age,  a 
man  may  often  prolong  his  life  and  greatly  add  to  the  comfort  of  his 
remaining  years  by  adhering  to  these  rules.  Yet  there  are  many 
instances  of  those  whose  constitutional  vigour  is  so  great  and  whose 
appetite  for  the  good  things  of  the  table  remains  so  keen  that  they 
are  unable  or  unwilling  to  listen  to  the  dictates  of  reason.  I  recol- 
lect an  instance  of  a  gentleman  who,  in  the  enjoyment  of  almost  per- 
fect health  at  the  advanced  age  of  ninety-four  suddenly  terminated  his 
life  by  an  uncontrollable  indulgence  in  lobster  salad.  The  idea  is 
prevalent  with  some  people  that  the  quantity  of  food  and  stimulants 
should  be  xncr  tdiSed  pari  passu  with  age,  but  this  is  as  wrong  in  theory 
as  it  is  pernicious  in  practice,  and  the  simple  fact  that  an  article  of 
particularly  rich  or  hearty  food  has  been  enjoyed  with  impunity  for 
many  years  is  no  argument  that  it  can  be  indefinitely  taken  in  the 
same  degree,  although  this  reasoning  is  very  often  encountered. 

In  commenting  upon  Prof.  Humphrey's  report  upon  centenarians, 
made  for  the  British  Medical  Association,  in  1887,  Dr.  Yeo  observes: 
"  Their  habits  in  eating  and  drinking  tended,  as  a  rule,  to  great  mod- 
eration in  both.  ...  Of  animal  food  the  majority  took  but  little. 
,  .  .  The  exact  quantity  is  mentioned  in  nine  instances  :  One  took 
12  ounces,  one  6,  one  5,  and  six  4  ounces  daily.  In  the  use  of  alco- 
holic drinks  we  also  find  evidence  of  great  moderation." 

Some  more  recent  investigations  of  the  dietetic  habits  of  men 
over  one  hundred  years  of  age  show  considerable  diversity  ;  thus,  for 
example,  some  were  found  who  ate  but  one  meal  a  day,  while  others 


AGE   AND   FOOD. 


287 


ate  four  or  five  ;  some  drank  but  little  fluid,  others  took  a  great  deal ; 
some  were  total  abstainers  from  alcohol,  and  others  were  not. 

Persons  who  attain  to  very  advanced  age  are  almost  invariably  of 
spare  habit,  and  the  universal  testimony  in  regard  to  centenarians  is 
that  they  have  never  abused  food  or  drink,  and  that  in  the  latter 
years  of  life,  at  least,  they  have  been  very  abstemious  in  the  use  of 
meat.  In  fact,  Nature  usually  furnishes  a  hint  in  this  direction  by 
depriving  them  of  their  teeth,  making  it  practically  impossible  to  eat 
animal  food,  which  requires  mastication,  and,  as  Yeo  suggests,  "  if  ar- 
tificial teeth  are  used  for  the  purpose  of  continuing  a  diet  composed 
of  animal  flesh,  they  will  not  prove  an  unqualified  advantage." 

Next  in  importance  to  diminishing  the  quantity  of  food  in  the 
diet  of  the  aged  (especially  the  proportion  of  fats  and  proteid  ma- 
terial) should  be  considered  the  necessity  of  regularity  in  "diet,  both 
in  regard  to  the  general  character  of  the  food  taken  and  the  times 
of  eating. 

If  the  teeth  are  absent,  tough  vegetables  and  meats  must  be 
avoided,  yet  the  food  should  not  be  wholly  fluid,  for  some  mastica- 
tion should  be  performed  in  order  to  maintain  the  salivary  flow. 
Plenty  of  time  should  be  allowed  for  this  purpose. 

Any  sudden  changes  in  diet  should  be  avoided,  and  the  intervals 
between  the  ingestion  of  food  should  not  exceed  six  or  eight  hours. 

It  is  very  common  for  elderly  people  to  awaken  early  in  the  morn- 
ing at  three  or  four  o'clock  and  to  be  unable  to  drop  off  to  sleep 
again,  but  if  they  have  some  light  form  of  nourishment  at  the  bedside, 
such  as  a  glass  of  milk  or  a  little  gruel,  which  they  can  take  at  that 
time,  they  will  often  continue  their  sleep. 

Malt  liquors  are  very  good  for  the  aged,  and  a  moderate  amount 
of  alcohol  acts  as  a  tonic  and  supplies  them  with  needed  energy  for 
digestion  and  other  functions. 

Yeo  gives  the  following  suggestions  in  regard  to  the  diet  of  the 
aged,  which  are  so  useful  that  they  will  be  quoted  in  full : 

"  Of  animal  foods  best  suited  for  this  time  of  life  the  following 
may  be  mentioned.  When  the  organs  of  mastication  are  altogether 
inefficient  these  foods  should  be  minced  or  pounded  into  a  paste  or 
otherwise  finely  subdivided : 

"Young  and  tender  chicken  and  game  and  other  tender  meats. 

*'  Potted  chicken,  game,  and  other  meats,  sweetbread. 

"White  fish,  as  soles,  whiting,  smelts,  flounders,  etc.  Best  when 
boiled. 

"Bacon,  grilled;  eggs  lightly  cooked  or  beaten  up  with  milk, 
etc. 

"  Nutritious  soups,  such  as  chicken  purees  or  fish  pur<fes,  beef  tea, 
mutton  and  chicken  broths. 

"  Milk  in  all  forms,  when  easily  digested. 


288  FOODS   REQUIRED   FOR   SPECIAL   CONDITIONS. 

*•  Beef  tea  and  milk  supply  the  needed  mineral  substances,  and  the 
former  is  an  excellent  stimulant. 

"The  addition  to  milk  of  an  equal  quantity  of  Vichy  water,  warm, 
or  of  warm  water,  will  often  help  to  make  it  agree. 

"  Of  vegetable  foods  the  following  are  all  suitable : 

"Bread  and  milk  made  with  the  crumb  of  stale  bread  and  without 
any  lumps. 

"  Porridge  and  oatmeal  gruel. 

"  Puddings  of  ground  rice,  tapioca,  arrowroot,  sago  macaroni 
with  milk  or  eggs  and  flavoured  with  some  warm  spices,  or  served 
with  fruit  juice  or  jelly;  bread  and  butter,  at  least  a  day  old;  rusks 
for  soaking  in  tea,  or  milk,  or  water. 

"  Artificial  foods,  consisting  of  predigested  starches.  The  digestive 
ferments  are  scantity  provided  by  the  digestive  organs  at  this  age, 
and  soluble  carbohydrates  are  valuable  for  maintaining  the  body 
heat. 

"  All  farinaceous  foods  should  be  submitted  to  a  high  tempera- 
ture for  some  time,  so  as  to  render  the  starch  granules  more  easy  of 
digestion. 

"  Vegetable  />ur/es  of  all  kinds  may  b*e  taken  in  moderation — e.  g., 
potatoes,  carrots,  spinach,  and  other  succulent  vegetables. 

"  It  is  important  that  the  use  of  potatoes  and  fresh  vegetables 
should  not  be  neglected ;  otherwise  a  scorbutic  state  of  the  body  may 
be  engendered. 

"  Stewed  celery  and  stewed  Spanish  or  Portugal  onions. 

"  Stewed  or  baked  fruits  and  fruit  jellies  and  the  pulp  of  per- 
fectly ripe  raw  fruits  in  small  quantity. 

"  The  acidity  of  certain  stewed  fruits  may  be  advantageously 
neutralised  by  the  addition  of  a  little  bicarbonate  of  soda  so  as  to 
avoid  the  use  of  a  large  quantity  of  cane  sugar  to  sweeten  it,  as  this 
is  apt  to  cause  gastric  fermentation  and  acidity.  In  stewing  fruit, 
about  as  much  soda  as  will  cover  a  shilling  should  be  added  to  each 
pound  of  fruit. 

"  Aged  persons  often  require  their  foods  to  be  accompanied  with 
some  kind  of  condiment,  which  promotes  their  digestion  and  prevents 
flatulence. 

"  Caviare  and  the  roes  of  smoked  and  salted  herrings  are  of  this 
nature. 

"  For  sweetening  food,  milk  sugar  is  much  less  prone  to  excite 
acid  fermentation  than  cane  sugar. 

"  A  very  digestible  form  of  fat — when  it  is  needed — is  cream, 
mixed  with  an  equal  quantity  of  hot  water  and  about  ten  drops  of 
sal  volatile  to  each  fluid  ounce." 


BODY   WEIGHT   AND   FOOD.  289 


INDIVIDUAL    SIZE    AND    FOOD. 

The  size  of  the  body  has  more  influence  than  its  weight  upon  the 
quantity  of  food  consumed.  In  infant  feeding  the  relationship  is 
made  the  subject  of  careful  study  (see  Infant  Feeding),  but  in  adults 
there  is  more  variation.  As  a  general  rule,  persons  of  large  frame 
eat  in  proportion  to  their  size,  and  vice  versa,  but  there  are  many 
exceptions  familiar  to  all,  and  some  very  corpulent  persons  are  very 
abstemious  at  the  table.  Because  most  persons  eat  more  than  they 
really  need,  a  man  of  large  frame  can  often  eat  less  than  one  of  small 
size,  and  yet  have  plenty. 

Attempts  have  been  made  to  demonstrate  that  a  preponderance 
of  animal  or  vegetable  food  respectively,  or  of  some  particular  sys- 
tem of  diet,  influences  the  stature  of  men.  Of  course,  children  who 
receive  insufificient  food  or  food  poor  in  quality  may  be  half  grown, 
but  beyond  that  fact  theories  as  to  the  specific  influence  of  different 
classes  of  food  upon  the  development  of  the  body  are  founded  upon 
ignorance  of  the  natural  history  of  the  different  races  of  man.  The 
diet  of  bushmen,  Australians,  and  Fuegians  presents  instructive  ex- 
amples of  tribes  with  large  or  small  bodies,  demonstrating  that  "it  is 
not  quality  or  monotony  of  food,  but  its  quantity  that  affects  devel- 
opment "  (Gerland). 

BODY   WEIGHT    AND    FOOD. 

The  question  as  to  how  far  gain  or  loss  in  the  body  weight  may 
be  taken  as  an  indication  of  the  appropriateness  of  diet  is  important. 
In  prescribing  systems  of  diet  for  many  diseases,  such  as  dyspepsia, 
obesity,  diabetes,  phthisis,  etc.,  it  is  very  important  to  have  the  pa- 
tient weighed  systematically  at  least  once  a  week,  and  good  scales 
are  very  useful  in  the  physician's  office.  Care  should,  of  course,  be 
observed  that  changes  in  clothing  are  not  allowed  to  interfere  with 
the  accuracy  of  the  observations.  Loss  of  weight,  under  some  con- 
ditions, may  be  much  more  rapid  than  gain  ever  is.  The  latter  at 
best  does  not  usually  proceed  at  a  rate  of  more  than  two  or  three 
pounds  in  a  week,  even  during  convalescence  from  such  an  illness  as 
typhoid  fever  ;  but  in  diseases  like  cholera,  for  example,  in  which 
emaciation  is  extremely  rapid,  the  loss  of  weight  may  amount  to  two 
or  three  pounds  a  day,  or  possibly  more. 

In  some  diseases  a  fallacy  arises  in  comparing  food  consumption 
with  body  weight.  In  fevers  there  is  usually  loss  of  weight,  but  this 
is  not  always  the  case.  Sometimes  in  aseptic  fevers  the  weight  may 
remain  uniform;  and  in  phthisis  there  is  sometimes  uninterrupted 
gain  during  a  moderate  hectic.  Leyden  has  found  that  in  fever, 
while  the  albuminous  ingredients  of  the  body  are  diminishing,  there 


2QO  FOODS   REQUIRED    FOR    SPECIAL   CONDITIONS. 

may  be  more  water  stored  in  the  tissues,  and  in  cases  of  anasarca  and 
dropsical  accumulations  of  rapid  development  it  is  quite  possible  for 
the  weight  to  increase,  while  in  reality  the  body  is  rapidly  wasting 
away,  and  it  would  be  a  very  grave  mistake  to  deduce  any  conclu- 
sions for  feeding  the  patient  from  the  weight  alone.  Another  impor- 
tant consideration  is  the  rapidity  of  loss  of  waste  food  products  from 
the  body. 

The  normal  weight  of  feeces  which  should  be  voided  each  day  is 
five  or  six  ounces — about  one  fourth  of  which  is  solid  matter,  the  rest 
water.  Many  persons  do  not  pass  over  half  this  quantity  for  days 
together,  and  thus  go  on  accumulating  waste  material,  which  adds  to 
their  weight.  The  same  disproportion  between  food  ingestion  and 
the  elimination  of  urea  and  different  salts  in  the  urine  may  exist. 
Moreover,  the  loss  of  weight  by  excessive  perspiration  may  reach  a 
pound  or  two  a  day.  Athletes  subjected  to  violent  physical  strain 
and  stokers  working  in  great  heat — sometimes  of  120°  F. — may  lose 
two  pounds  in  an  hour  in  this  manner.  The  night  sweats  of  phthisis 
cause  considerable  actual  loss  in  weight,  besides  the  exhaustion  which 
they  occasion.  The  loss  of  weight  through  the  aqueous  vapour  and 
carbon  dioxide  in  the  lungs  may  vary  somewhat,  although  it  is  less 
changeable  than  might  be  supposed. 

For  all  these  reasons  it  is  necessary  to  be  somewhat  cautious  in 
accepting  conclusions  from  the  scales  for  application  in  ordering 
more  or  less  food,  or  altering  its  character. 

The  weighing  of  infants  immediately  before  and  after  nursing  at 
the  breast  is  an  excellent  and  fairly  accurate  method  of  determining 
how  much  food  they  are  getting,  and  infants  whose  nutrition  gives 
any  cause  for  anxiety  should  be  frequently  weighed,  for  in  them,  for 
obvious  reasons,  the  record  of  slight  variations  in  weight  can  be 
much  more  accurately  utilised  in  regulating  feeding. 

SEX  AND   FOOD. 

The  relation  of  sex  in  regard  to  food  affects  the  quantity  rather 
than  the  quality,  excepting  among  a  few  rude  tribes  where  supersti- 
tion is  allowed  full  sway.  The  northern  Eskimos,  for  instance,  have 
a  belief  that  if  women  eat  eggs  they  cannot  become  pregnant,  which 
is  in  curious  contrast  to  the  reputation  for  aphrodisiac  effects  which 
this  food  has  among  civilised  people  !  (See  Eggs,  page  90.)  Women 
eat  less  food  than  men  relatively  because  their  average  size  is 
smaller,  and  also  absolutely  because  they  do  less  work  and  lead  a 
more  indoor  life.  The  difference  is  slight,  and  when  other  conditions 
are  equalised  the  question  of  sex  has  very  little  influence  upon  the 
quantity  of  food  consumed. 

Generally  speaking,  women's  bodies  are  smaller  than  men's,  their 


DIET   AND   RACE. 


291 


digestive  processes  are  somewhat  less  active,  and  they  have  greater 
tendency  to  constipation. 

About  the  only  way  in  which  sex  affects  the  quality  of  food  con- 
sumed is  in  the  somewhat  greater  fondness  for  sweets  and  confec- 
tionery exhibited  by  females,  but  this  can  be  shown  to  be  due  more 
to  other  considerations  of  habit  and  custom  than  to  sex.  The  use 
of  tobacco  by  many  men,  for  instance,  makes  them  care  less  for  such 
foods. 

DIET  AND  HEREDITY. 

The  influence  of  heredity  upon  diet  is  not  very  striking.  Children 
are  sometimes  supposed  to  inherit  likes  and  dislikes  for  particular 
foods,  whereas  they  are  merely  acquired  tastes  from  the  circumstance 
that  they  have  certain  foods  offered  them  at  home  to  the  exclusion 
of  others.  The  functions  of  the  stomach  and  intestines  appear  to  be 
somewhat  hereditary.  Violent  seasickness  and  a  tendency  to  bilious- 
ness and  constipation  in  some  persons  and  the  prompt  vomiting  of 
the  contents  of  an  overloaded  stomach  in  others  is  sometimes  a 
family  trait,  running  through  three  or  four  generations.  So  is  occa- 
sionally the  inability  to  digest  special  foods,  such  as  crustaceans, 
strawberries,  etc.,  but  such  instances  are  rare. 

Unfortunately,  the  abuse  of  alcohol  is  very  strongly  hereditary — 
so  much  so  that  the  children  of  inebriate  parents  should  be  protected 
as  long  as  possible  from  learning  the  taste  of  either  beer,  wine,  or 
spirits. 

Heredity  has  some  influence  in  disorders  of  food  assimilation, 
like  gout  and  diabetes,  and  in  such  cases  improper  diet  and  careless 
habits  of  eating  may  develop  latent  disease. 

DIET  AND   RACE. 

The  food  of  prehistoric  man  necessarily  consisted  of  the  simplest 
elements,  represented  by  fruits,  berries,  nuts,  insects,  and  an  occa- 
sional piece  of  raw  fish  or  meat.  Such  food  is,  in  fact,  the  diet  of 
primitive  tribes  to-day.  The  Fuegian  lives  chiefly  upon  shellfish 
and  seaweeds,  and  the  Central  African  dwarf  upon  plantains  and  in- 
sects (see  page  29).  The  name  "  Eskimo  "  was  first  applied  by 
natives  of  eastern  Canada  in  opprobrium,  to  signify  "raw-fish  eater." 

The  history  of  the  development  of  diets  and  of  food  cultivation 
and  preparation  is  practically  a  history  of  the  progress  of  culture, 
and  most  of  our  present  foods  were  quite  unknown  to  our  earliest 
progenitors.  The  discovery  of  the  uses  of  fire  greatly  increased  the 
variety  of  available  foods  for  man,  for  all  the  cereals  which  are  cul- 
tivated require  its  use  to  fit  them  for  digestion.  As  Gerland  has 
said,  men  obtain  their  food  from  natural  products,  by  cultivation,  or 
by  barter  and  commercial  exchange,  according  as  nomadic  or  fixed 


2Q2  FOODS   REQUIRED   FOR   SPECIAL   CONDITIONS. 

habits  predominate,  and  "  no  mere  hunting  or  fishing  tribe  can  be 
large  and  remain  in  one  place,"  for  it  is  estimated  that  in  the  tem- 
perate zone  to  support  one  man  by  these  means  at  least  sixteen 
square  miles  of  territory  are  necessary. 

Many  a  tribal,  and  even  national  war  has  been  the  more  or  less 
direct  outcome  of  the  necessities  of  obtaining  food  supply  from  distant 
sources,  and  the  economic,  commercial,  and  social  development  of 
all  matters  pertaining  to  food  among  civilised  people  to-day  far  ex- 
ceeds in  importance  all  other  practical  questions.  As  man  advanced 
in  culture  and  began  to  live  in  communities  where  division  of  labour 
became  an  important  factor  in  development,  preference  to  some  ex- 
tent superseded  necessity  in  the  selection  of  diet,  and  as  food  acquired 
a  commercial  value,  more  and  more  labour  was  bestowed  upon  its 
preparation  and  preservation,  until  at  the  present  time  the  rich  are 
able  to  select  their  diet  with  almost  total  disregard  of  season  or 
climate,  and  even  the  common  labourer  finds  it  economical  to  eat 
some  foods  which,  like  sugar  or  tea,  may  have  been  transported  many 
thousands  of  miles. 

Following  is  a  synopsis  of  an  exceedingly  interesting  report 
kindly  written  for  me  by  Dr.  Frederick  A.  Cook,  the  physician  to  the 
Peary  expedition  to  northwestern  Greenland  in  1891-92,  which  is 
appended  to  illustrate  the  dietetic  habits  of  a  race  which,  for  nearly 
a  thousand  years,  are  believed  to  have  been  practically  isolated 
from  commercial  or  social  relations  with  any  of  their  neighbours. 
There  is  so  little  scientific  information  existing  in  regard  to  the  di- 
etetic habits  of  the  tribe  of  Eskimos  which  he  studied,  who  live  the 
farthest  north  of  any  people  in  the  world,  that  his  statements  will 
be  found  of  exceptional  interest.  One  cannot  peruse  the  account 
without  being  impressed  with  the  fact  that  generalisations  in  regard 
to  the  influences  of  diet  upon  the  system  should  be  made  with  great 
caution  when  applied  to  different  races  of  man.  For  example,  both 
scurvy  and  rheumatism  are  sometimes  attributed  to  an  excessive 
meat  diet,  yet  the  Eskimo  has  no  starchy  food  at  all  and  does  not 
suffer  from  these  diseases,  and,  moreover,  his  bodily  vigour  and  power 
of  endurance  compare  favourably  with  that  of  any  other  race  or  class 
of  men,  and  in  some  respects  it  is  greater  than  that  possessed  by 
others. 

Dr.  Cook  says  in  regard  to  the  Eskimos  of  northwestern  Green- 
land:  "They  usually  eat  but  one  meal  a  day,  which  they  take  at 
irregular  times,  being  people  without  restrictions  of  any  kind. 
They  can  be  seen  eating  and  drinking  whenever  able  to  procure 
sustenance.  Their  diet  consists  almost  exclusively  of  meat,  com- 
posed principally  of  the  muscular  tissues  of  the  following  animals, 
in  the  order  of  their  importance  to  the  natives:  Seal,  walrus,  nor- 
whale,  white  whale,  polar  bear,  reindeer,  arctic  hare,  and  sea  fowls, 


DIET   AND  RACE. 


293 


such  as  guillemots,  gulls,  eider  ducks,  etc.  When  food  is  scarce 
they  eat  every  part  of  the  animal,  including  the  stomach  and  intes- 
tines ;  indeed,  the  only  vegetable  food  that  the  most  northern  Es- 
kimo can  obtain  consists  of  the  contents  of  the  stomach  of  the 
reindeer  (lichens),  which  he  is  only  occasionally  able  to  secure.  The 
women  and  children  sometimes  eat  flowers  of  the  arctic  poppies 
and  the  so-called  scurvy  grass,  but  never  to  any  great  extent.  In 
times  of  famine,  in  order  to  prevent  wholesale  starvation,  the  aged 
are  turned  out  to  starve  to  death,  and  their  bodies  are  then  devoured 
by  the  more  vigorous  members  of  the  tribe.  Occasionally,  when 
the  old  people  are  shrewd  and  active,  the  younger  children  are  sac^ 
rificed  for  this  purpose.  As  a  rule,  the  Eskimo  will  not  eat  dogs, 
but  when  food  is  scarce  dogs  are  first  added  to  their  larder,  and 
when  the  last  dog  has  been  eaten,  human  beings  come  next  in  order. 

"  One  of  the  greatest  delicacies  is  old  seal.  A  native  never 
wastes  the  carcass  of  an  animal ;  if  he  should  kill  the  seal  fifty  or 
a  hundred  miles  from  home  he  will  bring  it  to  shore  and  cache  it  in 
such  a  way  that  the  foxes,  bears,  and  birds  cannot  attack  it.  He  then 
leaves  it,  and  may  not  return  for  two  or  three  years,  when  he  comes 
back  in  anticipation  of  a  great  feast,  for  the  old  seal  seems  to 
him  like  old  cheese  to  us,  and  he  enjoys  it  immensely,  although  a 
white  man  could  not  endure  the  odour.  I  have  known  twenty  indi- 
viduals to  eat  a  seal  of  this  character  in  less  than  two  hours,  leaving 
only  shreds  of  the  skin  after  them.  I  have  never  been  able  to  verify 
the  statement,  so  commonly  quoted,  '  that  Eskimos  can  eat  twenty 
pounds  of  meat  or  blubber.' 

"  Fully  two  thirds  of  the  Eskimo  food  is  eaten  raw,  and  one 
half  is  consumed  while  in  the  frozen  state.  When  an  Eskimo  woman 
starts  her  blubber  lamp  and  places  over  it  a  conlipsie  (the  name 
applied  to  their  primitive  stew  pot),  she  does  so  principally  to  obtain 
the  warm  drink  which  the  cooked  meat  affords.  It  cannot  be  said 
that  Eskimos  cook  their  meat  because  they  prefer  it  cooked,  but 
because  when  the  meat  is  heated  slowly,  as  it  can  only  be  heated 
by  their  primitive  method,  the  blood  and  fat  ooze  from  the  mus- 
cular tissues  and  form  a  thick  soup,  which,  aside  from  water,  is 
almost  their  only  drink,  and  a  cupful  of  this  beverage  is  offered  to 
every  guest.  The  natives  may  consume  three  or  four  hours  in  cat- 
ting one  meal,  and  when  they  have  thoroughly  gorged  themselves 
they  will  lie  down  and  sleep;  as  they  do  this,  however,  they  place 
before  themselves  a  dish  full  of  cooked  meat,  and  those  who  awake 
from  their  sleep  will  finish  their  meal,  but  on  rising  no  breakfast  is 
served,  for  the  Eskimo  who  has  a  day's  journey  before  him  would 
not  think  of  eating  before  starting.  He  claims  that  this  would 
prevent  his  ability  to  travel,  and  this  rule  the  Eskimos  apply  to  their 
dogs  as  well,  who  are  often  only  fed  every  two  days.     These  Eski- 


2Q4  FOODS   REQUIRED   FOR   SPECIAL   CONDITIONS. 

mos  are  as  irregular  in  their  habits  of  sleep  as  they  are  in  regard 
to  their  meals.  During  the  four  months  of  constant  sunshine  they 
usually  arise  when  the  sun  is  in  the  south,  but  the  Eskimo  never 
thinks  of  going  to  bed  until  he  is  sleepy,  so  that  in  time  of  excite- 
ment, when  there  is  a  new  arrival  or  in  the  pursuit  of  game,  he  will 
often  remain  awake  for  forty-eight  or  seventy-two  hours,  and  then 
he  will  sleep  '  until  the  spirit  of  sleep  has  left  him,'  as  he  ex- 
presses it. 

"  The  Eskimos  endure  fasting  very  well,  and  after  a  good,  full 
meal  they  can  fast  for  two  or  three  days,  apparently  without  seri- 
ous inconvenience.  Indeed,  when  food  is  scarce — which  usually 
happens  during  the  period  of  darkness — some  thrive  on  about 
one  meal  a  week,  but  they  appreciate  the  fact  that  he  who  is  not 
well  fed  cannot  encounter  fierce  storms,  and  no  one  who  has  not 
had  full  rations  would  think  of  venturing  out  in  severe  weather. 
During  the  tedious  night  of  four  months  these  Eskimos  appear  to 
undergo  a  state  of  hibernation,  eating  very  little  and  sleeping  a  great 
deal ;  their  otherwise  lively  spirits  are  more  or  less  subdued,  and 
while  they  try  to  keep  cheerful  they  are  apt  to  become  depressed 
and  debilitated,  and  they  are  not  capable  of  great  muscular  exercise 
during  this  time.  When  the  sun  returns  their  skins  are  somewhat 
jaundiced,  and  they  are  very  anaemic.  This  peculiar  effect  was  also 
produced  in  the  members  of  our  party  in  a  more  exaggerated  form, 
although  we  tried  many  methods  of  overcoming  the  depression,  and 
though  we  had  no  trace  of  scurvy  our  will  powers  were  lessened,  and 
our  ambition  was,  to  some  extent,  lost,  and  our  muscular  power  as 
well  was  much  reduced,  so,  that  a  walk  of  a  mile  produced  exhaus- 
tion. All  of  the  secretions  were  diminished,  particularly  those  of 
the  digestive  tract,  and  to  stimulate  these  taxed  my  mental  skill  for 
the  greater  part  of  the  winter  of  i89i-'92,  but  with  us,  as  with  the 
Eskimo,  as  soon  as  the  sun  returned  our  strength  and  ambition 
came  back,  and  we  felt  as  if  we  had  gained  a  new  lease  of  life  and 
were  ready  to  encounter  any  hardship. 

"  The  Eskimo  drinks  very  little  while  eating.  He  usually  defers 
that  for  some  time  afterwards,  or  perhaps  until  he  arises  next  morn- 
ing, when  he  drinks  a  great  deal,  and  while  I  have  not  measured  the 
quantity  of  water  consumed  by  any  definite  number  of  inches  in 
twenty-four  hours,  I  have  often  given  Eskimo  men  three  pints  of 
water  at  one  time,  and  nursing  women  two  quarts.  Before  starting 
upon  a  journey  a  native  will  fill  up  with  water.  It  should  be  re- 
membered that  these  people  use  no  free  salt  or  condiments. 

"  I  am  not  prepared  to  say  that  the  food  of  these  people  bears 
any  relation  to  their  stature,  as  other  factors  may  influence  their 
height,  but  their  large  abdominal  development  is  undoubtedly  due 
to  the  immense  quantity  of  food  and  drink  which  they  consume  at 


DIET   AND   RACE, 


295 


one  time.  "Variation  in  diet  does  not  seem  to  be  a  necessity  to  the 
Eskimo  unless  he  is  feeling  ill,  when  he  recognises  the  importance 
of  a  change  of  food  and  surroundings.  He  will  always  hail  with 
pleasure  the  first  bird,  deer,  or  walrus  of  the  season. 

"  The  Eskimo's  clothing  is  such  a  perfect  non-conductor  that  the 
temperature  does  not  vary  much  around  his  body,  and  in  summer  it 
is  practically  the  same  as  in  the  coldest  day  of  winter.  For  this 
reason,  the  extreme  cold  of  winter  does  not  call  for  a  large  quantity 
of  food,  but  a  native  knows  that  his  food  is  fuel  for  his  body,  and 
that  he  must  take  it  in  sufficient  quantity  to  develop  muscular 
power  and  animal  heat. 

"  The  Eskimo  mother  nurses  her  child  until  the  next  is  born  or 
shortly  before  it,  a  period  which  varies  in  from  one  to  eight  or  nine 
years,  but  the  average  time  is  four  years.  Long  before  the  mother 
weans  her  child  she  masticates  the  food,  opens  the  baby's  mouth, 
and  transfers  the  food  from  her  own  mouth  to  the  baby's,  very  much 
as  a  pigeon  does,  and  the  child  thus  brought  up  would  not  think  of 
taking  up  pieces  of  meat  or  toys  or  anything  else  to  put  into  its 
mouth,  for  it  will  take  nothing  except  from  its  mother. 

"  The  members  of  our  expedition  took  very  few  forced  marches 
in  low  temperatures.  The  one  over  the  interior  of  Greenland  was 
undertaken  at  the  time  of  year  when  the  thermometer  ranges  from 
5°  F.  below  zero  to  40°  above. 

*'  The  quantity  of  food  consumed  per  man  every  twenty-four 
hours  upon  this  expedition  was  as  follows : 

"  Pemmican i^  pound. 

Bacon,  fat 6  ounces. 

Powdered  pea  soup 2       " 

Dry  ship  biscuits 12       " 

Condensed  milk 3      " 

"  A  quart  of  tea  with  perhaps  a  pint  of  water  was  our  only  drink, 
but  we  had  no  drink  through  the  day  while  on  the  march,  and  often 
were  unable  to  secure  more  fluid  than  two  cups  each  morning  and 
night.  The  pemmican  was  composed  of  dried  beef  and  beef  tal- 
low, half  and  half,  a  few  currants,  and  a  little  sugar,  but  no  salt. 
On  several  expeditions  during  the  spring  of  1892,  while  the  ther- 
mometer ranged  from  20°  to  40°  F.  below  zero,  the  members  of  the 
party  always  consumed  large  quantities  of  food.  This  was  not, 
however,  until  they  had  been  out  two  or  three  days,  when  the 
amount  of  food  which  they  could  devour  seemed  almost  un- 
limited. There  was  no  time  that  we  craved  for  fat.  We  enjoyed 
the  pemmican  immensely,  but  that  was  because  we  had  nothing  else. 
During  the  extreme  cold  weather,  while  in  the  field,  we  took  more 
kindly  to  fats,  but  never  in  preference  to  other  foods.  Canned 
meats,  for  some  unexplained  reason,  were  soon  in  disfavour,  for  the 


2q6  foods  required  for  special  conditions. 

variety  and  character  of  the  food  seemed  to  be  of  very  little  con- 
sequence ;  indeed,  our  appetites  were  such  that  we  were  ready  to  eat 
anything  and  everything  placed  before  us.  We  were,  however, 
always  liberally  supplied  with  hydrocarbons,  and  I  believe  had  this 
not  been  the  case,  a  demand  for  them  would  soon  have  arisen,  for 
the  most  valuable  food  for  a  polar  expedition  is  composed  largely 
of  hydrocarbons. 

"  The  most  important  articles  of  diet  for  a  polar  expedition  we 
found  to  be  pemmican,  cranberry  sauce,  tea,  coffee,  chocolate,  pre- 
served milk,  sugar,  ham,  cheese,  bacon,  oleomargarine,  lard,  pickles, 
lime  juice,  dried  fish,  beef-soup  tablets,  wheat,  corn,  rye  flour,  rice, 
hominy,  oatmeal,  dried  vegetables,  and  a  liberal  supply  of  all  kinds 
of  canned  vegetables,  particularly  canned  tomatoes,  peas,  beans, 
corn,  canned  soups,  and  dried  fruits.  Lime  juice  was  not  served 
regularly  to  the  members  of  the  expedition,  and  I  think  nothing  is 
to  be  gained  by  so  doing.  For  some  of  the  members  of  the  party 
it  was  decidedly  injurious,  but  others  called  for  it  occasionally  as  a 
refreshing  drink. 

''  The  average  weight  of  these  northern  Eskimo  men  is  one  hun- 
dred and  thirty-five  pounds,  but  that  of  the  women  one  hundred 
and  eighty-eight  pounds.  Obesity  is  foreign  to  the  Eskimo,  and 
leanness  is  equally  rare." 

CLIMATE  AND  SEASON   AND   FOOD. 

Much  has  been  written  about  the  need  of  man  changing  his 
diet  when  he  removes  from  one  climate  to  another,  in  the  belief  that 
the  natives  always  eat  the  kind  of  food  best  adapted  to  the  climate 
in  which  they  live.  This  is  superficial  reasoning,  and  too  much  im- 
portance is  attached  to  the  relations  of  climate  to  diet/>er  se.  As  a 
matter  of  fact,  the  natives  of  a  country  eat  what  they  can  obtain 
easiest,  or  what  their  habits  and  mode  of  life  have  accustomed  them 
to  in  the  struggle  for  the  survival  of  the  fittest.  "  Climate  affects 
diet  mainly  by  the  supply  it  affords  "  (Chambers). 

"The  national  dietary  is  determined  largely  by  the  climate  and 
nature  of  the  available  soil,  and  among  civilised  communities  it  is 
largely  modified  as  facilities  for  commerce  and  interchange  of  food 
products  are  increased. 

"  Maritime  people  naturally  derive  much  nitrogenous  food  from 
the  sea,  as  fish,  molluscs,  crustaceans,  etc.  Among  the  residents 
of  the  far  North  albuminous  and  fatty  diet  predominates,  and  the 
coarser  cereals — barley,  rye,  oats,  etc. — being  more  hardy,  predomi- 
nate in  their  food.  Barley  grows  the  farthest  north  of  all  the  cere- 
als "  (Clark). 

The  Hindu  subsists  mainly  upon  rice,  one  of  the  simplest  types 
of  farinaceous  food,  and  he  derives  his  nitrogen   from  corn.     He 


CLIMATE   AND   SEASON    AND   FOOD.  207 

must  consequently  eat  a  large  bulk  of  food  in  order  to  obtain  suffi- 
cient nitrogen  for  the  needs  of  the  system;  his  digestive  organs 
enlarge,  and  he  finds  the  means  of  stimulating  them  by  the  free 
use  of  condiments  of  various  sorts.  Bulky  and  fibrous  vegetable 
food  distends  the  alimentary  canal.  The  natives  of  very  hot  coun- 
tries live  mainly  upon  vegetable  and  starchy  foods,  eating  cereals, 
green  vegetables,  and  pulpy  fruits  which  contain  water,  salts,  and 
acids  in  abundance,  which  are  cooling  and  refreshing.  As  a  rule, 
they  eat  less  animal  food  than  do  the  natives  of  temperate  and  arc- 
tic regions,  nor  do  they  require  fats  in  excess,  although  they  take 
some  fats  and  oils. 

While  these  statements  apply  to  a  majority  of  mankind,  they  are 
by  no  means  without  exception,  and  it  must  not  be  argued  that 
because  a  tribe  eats  the  only  food  which  Nature  has  provided, 
they  could  not  live  equally  well  in  their  own  climate  upon  other 
food,  if  they  could  obtain  it.  Far  from  depending  solely  upon  vege- 
table food,  most  savage  tribes  living  in  the  torrid  zone  eat  meat  rav- 
enously when  they  can  get  it,  and  often  prefer  it  in  an  advanced 
stage  of  decomposition. 

The  New  Zealander  and  South  Sea  Islander  choose  a  varied  diet 
of  fish,  eggs,  roots,  seeds,  berries,  seaweeds,  and  meat  if  obtainable 
(see  page  29). 

As  pointed  out  by  Chambers,  the  Pampas,  who  eat  flesh  and  drink 
water  only,  thrive  on  hot  arid  plains,  and  so  do  the  Nubian  Arabs, 
while  the  peasants  of  northern  Norway  and  southern  Spain  live  alike 
almost  wholly  on  breadstuff's  without  meat.  He  says  that  "the  im- 
mediate transition  from  a  purely  animal  to  a  purely  vegetable  diet, 
though  borne  by  the  individual,  is  fatal  to  the  race,"  and  "the  best 
diet  in  the  abstract  is  a  mixed  diet,  and  mixed  in  the  proportion  se- 
lected by  the  experience  of  most  civilised  nations,  and  it  is  also  best 
for  the  individual  who  is  accustomed  to  it  to  adhere  to  under  what- 
ever sky  he  may  be  wandering."  In  changing  residence  from  one 
extreme  of  climate  to  another  it  is  not  advisable  to  alter  the  diet 
too  suddenly,  and  more  must  depend  upon  the  previous  habits  and 
occupation  of  the  individual  than  upon  external  temperature.  Meat 
eaters  find  it  easier  to  adopt  quickly  another  form  of  diet  than  vege- 
tarians. 

The  English  soldiers  transported  to  India  or  Africa  are  not  re- 
quired to  become  exclusive  vegetarians;  and  the  French  in  .Africa 
or  Panama  have  done  best  upon  a  mixed  diet. 

"Well-clad  and  sheltered  sftldiers  require  less  rations  than  poorly 
clad  men  exposed  to  the  weather — a  good  thing  to  know  in  times  of 
great  privation  "  (Woodruff). 

Men  often  become  involuntary  vegetarians  while  travelling  in 
hot  climates  from  inability  to  procure  meat,  and  may  partially  starve 


2q8         foods  required  for  special  conditions. 

themselves  from  lack  of  appetite  for  monotonous  food,  variety  being 
unobtainable.  This  leads  them  to  resort  to  strong  condiments, 
spices,  curry,  etc.,  to  stimulate  the  appetite. 

Many  persons,  especially  those  past  middle  life  and  people  with  a 
tendency  to  corpulency,  find  that  during  the  heat  of  the  summer  sea- 
son, and  especially  during  the  prevalence  of  "heat  waves,"  they  are 
in  much  better  health  when  they  abstain  from  hot  soups,  fat,  and 
meat,  and  take  but  little  animal  food  of  any  kind.  The  total  quan- 
tity of  food  eaten  may  advantageously  be  reduced  at  this  time  of 
the  year  as  much  as  one  sixth,  or  even  one  fourth.  Most  persons 
find  this  out  as  a  matter  of  individual  experience;  but  there  are 
others  who  should  be  especially  directed  in  the  matter,  and  the  rule 
applies  to  infants  as  well  as  adults.  The  diet  in  winter  should  com- 
prise both  more  nitrogen  and  more  carbon  than  in  summer. 

The  breakfast  hour  is  often  made  half  an  hour  or  an  hour  earlier 
in  summer  than  in  winter  to  advantage. 

The  thirst  engendered  by  living  in  hot  climates  is  conducive  to 
excessive  drinking,  and  as  the  water  is  often  bad,  an  additional  ex- 
cuse is  often  made  for  drinking  too  much  liquor.  By  these  means 
the  foundations  for  hepatic  and  renal  troubles,  cirrhosis,  and  Bright's 
disease  are  often  laid.  On  this  account,  in  very  hot  climates  strong 
alcoholic  drinks  ought  especially  to  be  avoided.  In  India  they  uni- 
formly disagree,  and  lighter  beverages,  such  as  beer  and  wines,  must 
be  taken  very  sparingly;  but  there  is  no  objection  to  tea,  coffee,  and 
chocolate. 


PART   V. 

FOOD   DIGESTION.— CONDITIONS   WHICH   ESPE- 
'  CIALLY   AFFECT   DIGESTION. 


HOURS  FOR   MEALS  AND  ORDER  OF  TAKING  FOOD. 

The  hours  for  taking  meals  which  are  commonly  selected  are 
those  which  are  best  adapted  to  the  varying  needs  of  the  system  at 
different  times  in  the  day,  and  experience  teaches  that  they  must  be 
varied  considerably  with  occupation.  In  the  larger  American  cities 
where  commerce  is  active,  and  many  men  are  subjected  during  the 
day  to  excitement,  hurry,  and  strain,  an  evening  dinner  hour  often 
better  meets  the  needs  of  the  system  as  well  as  the  requirements  of 
personal  c6nvenience.  In  the  rural  districts,  however,  and  in  many 
countries  where  life  is  less  hurried  and  active  than  under  the  condi- 
tions of  the  extraordinarily  rapid  growth  and  development  of  the 
United  States,  it  is  found  that  taking  the  heaviest  meal  at  noon 
agrees  better  with  the  wants  of  most  persons.  The  hours  for  infant 
feeding  are  described  under  the  heading  Infant  Feeding. 

Children  should  always  dine  early  in  the  day.  There  are  in  gen- 
eral three  systems  for  adults  in  regard  to  the  number  of  meals  and 
hours  for  taking  them  which  are  in  common  use,  in  which  two,  three, 
and  four  meals,  respectively,  are  eaten  in  the  twenty-four  hours. 

The  first  system,  which  is  in  vogue  in  France  and,  to  a  less  extent, 
elsewhere,  is  that  of  eating  but  two  substantial  meals  a  day.  On 
first  rising  in  the  morning,  a  cup  of  hot  coffee  or  chocolate  is  taken 
with  a  roll  or  some  other  simple  form  of  bread.  This  enables  two  or 
three  hours  of  moderate  work  to  be  accomplished  before  the  first 
real  meal,  which  is  a  breakfast  eaten  in  the  late  morning,  usually  at 
or  before  twelve  o'clock.  This  meal  is  substantial,  consisting  of  sev- 
eral courses  of  solid  food.  The  second  meal,  which  is  the  dinner,  is 
usually  eaten  between  six  and  seven  o'clock.  This  system  is  in  use 
among  workingmen  as  well  as  with  the  leisure  classes,  and  is  found 
well  adapted  to  their  habits  of  life.  Americans  travelling  abroad, 
who  are  accustomed  to  eat  a  heavier  meal  for  breakfast,  often  find 
some  difficulty  in  adapting  themselves  to  the  French  custom,  but 
many  learn  to  like  it,  and  as  the  travelling  public  are  commonly,  for 

299 


30O 


FOOD   DIGESTION. 


the  time  being,  a  leisure  class,  it  is  less  difficult  to  adapt  themselves 
to  new  customs  abroad  than  to  introduce  them  at  home. 

The  Germans  also  usually  take  a  cup  of  coffee  or  other  light 
beverage  and  a  roll  of  Butter-brod  soon  after  rising,  but  they 
dine  very  early,  often  at  half  past  twelve,  taking  a  heavy,  de- 
liberate meal  at  this  hour,  which  they  are  apt  to  follow  with  beer  and 
tobacco.  Their  offices  and  banks  open  early,  and  are  often  closed 
from  noon  until  three  o'clock,  when  they  are  reopened  until  five, 
whereas  in  most  cities  in  this  country  the  most  active  business  hours 
are  in  the  middle  of  the  day,  and  it  would  be  practically  impossible 
for  many  men  to  give  up  two  or  three  hours  at  this  time  to  eating 
and  social  converse.  The  Germans  usually  take  a  supper  with 
meat  at  a  somewhat  late  hour — between  half  past  seven  and  eight 
o'clock.  In  many  German  towns  it  is  customary  to  open  the  theatres 
as  early  as  six  o'clock,  so  that  the  performance  is  closed  in  time  for 
a  supper  at  nine.  The  habit  of  eating  between  meals  and  of  tak- 
ing occasional  light  lunches  in  the  afternoon  seems  to  be  more 
prevalent  there  than  elsewhere. 

In  England  it  is  a  very  common  custom  for  the  better  classes  to 
breakfast  at  eight  or  nine  o'clock,  lunch  or  dine  between  one  and 
two,  take  a  cup  of  tea  and  perhaps  a  biscuit  at  four  or  five,  and 
dine  or  sup  at  seven  or  eight  o'clock. 

In  the  United  States,  where  there  are  theoretically  no  class  dis- 
tinctions, they  practically  do  exist  very  strikingly  in  regard  to  the 
hours  for  taking  meals,  and  the  hard-working  labouring  class,  whether 
employed  in  the  city  or  country,  almost  universally  dine  at  noon. 
It  is  mainly  the  mercantile  and  professional  classes  in  large  cities 
who  dine  between  6  and  7  p.  m.,  while  the  more  fashionable  or  leisure 
classes  dine  even  later — sometimes  at  eight  o'clock.  Most  of  the 
latter,  however,  on  going  to  the  country  for  a  summer  holiday,  are 
accustomed  to  reverse  their  habits  and  dine  at  the  usual  country 
hour— at  one  o'clock,  taking  supper  at  half  past  six  or  seven.  In 
the  Southern  cities  it  is  quite  common  to  dine  in  the  neighbourhood 
of  half  past  two  or  three  o'clock.  Many  persons  in  cities  who  habit- 
ually dine  late  on  week  days  from  long-continued  custom,  on  Sun- 
days dine  shortly  after  noon,  taking  supper  in  the  evening.  This  is 
an  old  custom  handed  down  from  days  in  which  less  exacting  oc- 
cupations favoured  noon  dining  throughout  the  week,  but  due  in 
part  also  to  economical  reasons,  and  a  desire  to  make  the  work  for 
servants  as  light  as  possible  on  Sunday  afternoon.  While  those  in 
good  health  with  active  digestion  suffer  no  inconvenience  from  thus 
changing  the  hour  for  meals  on  one  day  in  the  week,  there  are  others 
who  find  that  it  disagrees  with  them  and  disturbs  their  digestion.  A 
hearty  meal  at  noon  following  a  very  light  breakfast,  consisting  of  a 
roll  and  cup  of  coffee  or  tea,  may  be  perfectly  digested  for  years. 


HOURS   FOR    MEALS   AND   ORDER   OF   TAKING   FOOD. 


301 


yet   reversing   the   order   of   the   meals   may  entirely  disorder   the 
digestion. 

For  professional  and  other  classes  of  men  in  the  United  States 
who  are  not  occupied  in  physical  labour  or  outdoor  pursuits  the  fol- 
lowing system  is  found  to  possess  decided  advantages :  A  breakfast 
is  taken  soon  after  rising,  at  half  past  seven  to  half  past  eight,  which 
consists  of  fresh  fruit,  porridge  or  oatmeal,  or  other  varieties  of 
cereals,  poached  eggs  or  omelet,  and  a  little  bacon  or  fresh  or  salt 
fish,  bread  and  butter,  tea  or  coffee.  The  lunch,  eaten  between  one 
and  two  o'clock,  may  consist  of  a  lean  chop,  or  a  piece  of  cold  ham, 
or  a  slice  of  rare  beef  with  some  stewed  or  baked  potatoes,  with  a 
simple  lettuce  salad,  or  perhaps  a  little  cheese  for  dessert.  If  a 
heavy  meal  is  taken  at  this  hour  by  persons  unaccustomed  to  it,  and 
who  have  had  a  breakfast  of  solid  food,  they  often  feel  dull  and 
sleepy  for  an  hour  or  two  thereafter,  and  are  consequently  inca- 
pacitated from  active  mental  exercise.  The  dinner  should  be  from 
half  past  six  to  half  past  seven,  after  the  principal  labours  of  the  day 
are  over,  and  at  an  hour  early  enough  to  allow  of  the  complete  diges- 
tion of  the  heaviest  meal  of  the  day  before  retiring.  This  may  con- 
sist of  several  courses,  which  are  conventionally  arranged  in  the 
order  which  appears  to  be  most  rational  and  physiological — namely, 
soup,  fish  or  an  entree,  a  steak  or  joint  with  potatoes  and  one  or 
two  fresh  vegetables,  a  salad,  and  a  light  pudding  or  cooked  fruit. 

A  clear  soup  at  the  commencement  of  a  meal  does  not  interfere 
with  digestion,  but  favours  it.  The  fluid,  if  taken  in  a  quantity  not 
exceeding  eight  or  ten  ounces,  is,  for  the  greater  part,  promptly 
absorbed  in  the  stomach,  and  its  warmth  and  the  sustenance  it  con- 
tains act  favourably  upon  the  circulation,  stimulate  the  secretion  of 
gastric  juice,  and  satisfy  temporarily  the  cravings  of  hunger  which 
are  not  met  by  the  taking  of  solid  food  until  after  it  has  been 
digested  for  some  time.  The  fish  or  entree  is  then  eaten  in  the 
earlier  stage  of  gastric  secretion  when  the  gastric  juice  has  not  yet 
attained  its  full  strength  and  quantity.  This  is  followed  by  the 
eating  of  meat,  which  is  destined  to  remain  in  the  stomach  for  several 
hours,  and  requires  all  the  energies  of  its  digestive  processes.  The 
saccharine  or  farinaceous  food,  which  does  not  undergo  digestion  in 
the  stomach,  is  taken  towards  the  end  of  the  meal,  when  it  remains  a 
less  time  in  the  stomach  than  animal  food. 

The  discussion  of  more  elaborate  dinners,  consisting,  as  they  do 
very  often,  of  a  dozen  or  more  separate  courses,  would  be  out  of 
place  in  this  volume.  Such  dinners  can  only  be  indulged  in  for  any 
length  of  time  by  those  whose  digestion  is  robust  and  whose  leisure 
and  comparative  freedom  from  care  and  anxiety  allow  them  to 
devote  abundant  time  and  physical  energy  to  their  meals  and  to 
secure  sulificient  holidays  and  trips  to  noted  spas  to  enable  them  to 


OQ2  FOOD   DIGESTION. 

periodically  relieve  the  digestive  system  of  the  strain  put  upon  it. 
Persons  who  rise  late  and  dine  early  should  eat  but  a  small  break- 
fast and  a  hearty  supper.  If  the  noon  dinner  is  replaced  by  a  light 
luncheon,  a  substantial  breakfast  should  be  eaten. 

Undoubtedly  it  is  usually  best  to  so  order  one's  occupation  that 
neither  severe  mental  nor  physical  labour  need  be  undertaken  imme- 
diately after  eating.  Yet  much  depends  upon  the  age  and  strength 
of  the  individual. 

At  one  of  the  largest  colleges  for  girls  in  New  England  the  pupils 
dine  at  one  o'clock,  and  many  of  them  commence  to  study  imme- 
diately thereafter,  or  at  2  p.  m.  ;  yet  cases  of  indigestion  are  compar- 
atively infrequent  among  them  ;  and  the  ordinary  day  labourer  begins 
his  work  again  without  detriment  almost  immediately  after  a  hearty 
noon  meal,  and  continues  it  while  gastric  and  intestinal  digestion  are 
still  necessarily  incompleted. 

Invalids  often  require  modification  in  the  accustomed  hours  for 
meals,  and  Balfour  says  that  "all  invalids  should  have  their  impor- 
tant meal  in  the  middle  of  the  day." 

Between  four  and  five  hours,  on  the  average,  must  be  regarded  as 
necessary  for  complete  digestion  of  a  mixed  meal. 

The  intervals  between  meals  should  be  regulated  with  reference 
to  individual  peculiarities.  As  a  general  rule,  convalescents  or  per- 
sons with  feeble  digestive  powers  and  poor  appetites,  who  are  unable 
to  eat  a  sufficient  quantity  of  food  at  any  one  meal,  should  be  fed 
more  frequently,  perhaps  four  or  five  times — that  is,  in  addition  to 
three  ordinary  meals,  they  should  have  light  lunches  in  the  middle 
of  the  forenoon  and  afternoon,  or  possibly  just  before  retiring.  The 
latter  is  particularly  to  be  recommended,  for  if  the  food  be  light  and 
nutritious,  such  as  a  bowl  of  gruel  and  a  glass  of  hot  milk,  or  a  cup 
of  cocoa  with  a  biscuit,  and  possibly  a  glass  of  beer,  sleep  is  not 
interfered  with,  but  is  promoted,  and  the  system  is  saved  from  too 
long  an  interval  of  starvation  between  the  hours  of  dinner  or  sup- 
per and  breakfast.  On  the  other  hand,  dyspeptics  and  patients  with 
gastric  catarrh  may  find  it  desirable  to  allow  an  interval  of  fully 
seven  hours  between  their  meals,  in  order  to  give  abundant  time  for 
the  digestion  of  one  meal  before  that  of  the  next  is  undertaken,  and 
they  should  stop  eating  short  of  repletion. 

There  are  others  whose  digestion  is  good,  but  constitutionally 
slow,  and  they  are  better  with  intervals  of  at  least  six  hours  between 
their  meals  ;  and  there  are  some  people  who  keep  in  better  health  on 
only  two  meals  a  day,  and  occasionally,  although  it  must  be  re- 
garded as  an  eccentricity,  except  in  the  case  of  some  savages  and 
the  Eskimos  (see  page  292),  there  are  persons  who  thrive  upon  but 
one  meal  a  day. 

The  monks  of  La  Trappe  eat  but  one  meal  daily,  as  a  religious 


APPETITE.  203 

custom,  at  which  they  consume  so  much  food  that  they  become  dull 
and  lethargic  for  several  hours  afterwards  (Combe). 

Many  savages,  like  the  Hottentots,  have  no  regular  times  for  eat- 
ing, but,  like  the  carnivores,  take  their  food  whenever  and  however 
they  can  best  obtain  it. 

The  business  or  professional  man  when  overworked  sometimes 
forms  the  habit  of  omitting  his  noon  luncheon;  but  this  custom, 
although  it  may  benefit  some  forms  of  dyspepsia,  is  a  pernicious 
one  in  the  majority  of  instances  if  long  continued. 

APPETITE. 

The  term  "  appetite  "  in  relation  to  dietetics  usually  means  a 
pleasurable  desire  for  food  or  drink,  whereas  hunger  and  thirst  im- 
ply a  craving  for  food  and  drink  respectively,  which  has  become 
disagreeable  or  positively  painful.  There  is,  however,  no  distinct 
Ime  of  demarcation  to  be  drawn  between  these  terms. 

The  appetite  for  food  is  a  most  capricious  sensation,  subject  to 
all  manner  of  disturbing  influences.  It  is  to  some  extent  appar- 
ently under  control  of  the  will,  in  that  it  can  be  trained  to  recur  at 
certain  intervals  before  taking  food.  In  a  normal  state  it  is,  there- 
fore, rhythmical,  and  it  may  then  be  taken  as  an  index  of  the  need 
of  food,  but  when  it  becomes  abnormal  it  is  a  very  unreliable  guide. 

"As  a  general  rule,  though  by  no  means  without  exception,  sub- 
stances pleasing  to  the  palate  are  useful  and  not  injurious  to  the 
organism  "  (Brunton). 

The  appetite  often  appears  with  great  suddenness,  either  inde- 
pendently or  as  the  result  of  directing  the  attention  to  matters  of 
food  and  eating.  It  may  depart  as  suddenly,  even  without  gratifi- 
cation, or  it  may  vanish  after  the  first  few  mouthfuls  of  food  are 
eaten,  although  it  was  apparently  vigorous  a  moment  before. 

The  appetite  is  aroused  by  a  variety  of  circumstances  and  con- 
ditions, both  physical  and  mental.  Such  are  the  smell,  taste,  and 
sight  of  food,  good  hygienic  surroundings,  exercise,  bathing,  cold  or 
stimulating  air,  agreeable  companionship,  pleasurable  mental  emo- 
tions, and  the  proper  preparation  and  serving  of  food.  It  may  be 
stimulated  by  bitters,  condiments,  and  in  some  cases  by  alcohol. 
Wine  drunk  between  meals  is  apt  to  spoil  the  appetite,  but  taken 
in  moderation  with  meals  it  may  increase  it. 

To  obtain  the  most  complete  satisfaction  from  the  sense  of  taste 
one  should  swallow  the  food,  and  not  merely  take  it  into  the  mouth. 

The  appetite  is  usually  somewhat  more  keen  in  winter  than  in 

summer,  but  many  persons  observe  no  difference.     It  is  depressed 

or    destroyed    by    mental    emotion,    especially   grief,    anxiety,  and 

worry  ;  by  the  sight,  smell,  or  taste  of  ill-prepared  or  improperly 

22 


204  FOOD   DIGESTION. 

cooked  or  badly  served  food ;  foul  air  and  poor  hygienic  surround- 
ings; fatigue  and  exhaustion;  many  diseases,  more  particularly 
febrile  diseases  and  most  gastric  disorders;  nausea;  the  use  and 
abuse  of  strong  condiments,  and  many  drugs,  notably  opium  and 
those  which,  like  potassium  iodide,  produce  a  continual  offensive 
taste  in  the  mouth;  the  abuse  of  alcohol;  eating  irregularly  and  at 
too  short  intervals. 

In  old  age  the  appetite,  especially  for  meats,  usually  becomes 
less  keen,  and  the  absence  of  teeth  contributes  to  the  loss  of  desire 
for  this  kind  of  food.     There  is  often  a  dislike  for  cold  fluids. 

A  voracious  appetite  sometimes  occurs  in  children  and  youth. 

Bulimia  is  the  name  given  to  this  condition,  which  is  by  no 
means  an  indication  of  vigour,  and  is  often  due,  according  to  Beale, 
to  an  irritable  condition  of  the  nerves  of  the  stomach,  and  may  be 
brought  about  by  eating  at  irregular  intervals,  which  results  in  dis- 
turbance of  the  gastric  secretion.  Such  children  are  usually  thin, 
and  are  encouraged  by  ill-advised  parents  or  attendants  to  gorge 
themselves  with  food  which  they  do  not  digest.  It  is  a  popular 
belief  that  the  presence  of  intestinal  worms  excites  a  ravenous  appe- 
tite. In  some  cases  this  may  be  true,  especially  of  round  worms 
{^Ascaris  lumbricoides),  which  are  very  active,  and  which  may  even  throw 
a  child  into  convulsions  by  local  irritation  of  the  intestine.  On  the 
contrary,  worms  of  any  sort  may  be  present  in  considerable  num- 
ber without  giving  rise  to  symptoms.  Persons  whose  appetites 
exceed  their  digestive  strength  do  well  to  eat  very  slowly.  By  so 
doing,  the  food  eaten  at  the  first  part  of  a  meal  may  become  par- 
tially absorbed  and  lessen  the  desire  for  more  before  the  meal  is 
over. 

The  appetite  is  very  dependent  upon  habit  and  upon  the  usual 
order  and  arrangement  of  the  meal.  An  attempt  to  eat  a  lump  of 
butter  alone  usually  fails,  but  it  is  easily  consumed  if  spread  upon 
bread.  Reversing  the  customary  order  of  the  different  foods  served 
at  a  dinner  usually  produces  disgust,  and  may  even  excite  nausea. 

Abnormal  Cravings. 

Instances  of  abnormal  cravings  for  food  are  familiar  to  every 
one.  They  sometimes  take  the  form  merely  of  an  inordinate  desire 
for  food  which  is  in  itself  wholesome  but  which  is  poorly  adapted 
to  an  existing  diseased  condition.  Such  desire  is  apt  to  come  in 
the  course  of  any  protracted  illness  in  which  a  very  restricted  diet 
has  been  maintained  for  weeks.  It  is  largely  psychic,  and  does  not 
necessarily  indicate  an  increased  appetite.  The  dysenteric  patient 
may  long  for  ham  or  pickles  or  vegetables,  or  the  very  obese  will 
beg  for  sweets,  preserves,  or  farinaceous  food. 

In  other  cases  the  .craving  may  be  an  indication  of  a  positive 


VARIETY   IN   DIET. 


305 


want  in  the  system,  as  when  a  scorbutic  patient  hungers  for  fresh 
fruit  and  vegetable  acids. 

In  no  disease  is  the  craving  for  food  of  every  kind  more  pro- 
nounced than  in  convalescence  from  typhoid  fever.  In  this  case 
the  hunger  can  hardly  be  considered  abnormal,  for  it  is  an  expres- 
sion of  the  need  of  wasted  and  exhausted  tissue  throughout  the  body 
for  nutriment. 

Patients  usually  find  it  most  difficult  to  give  up  the  class  of  foods 
which  they  well  know  does  them  most  harm.  The  subject  of  flatu- 
lent dyspepsia  longs  for  saccharine,  and  perhaps  amylaceous  or  fatty 
foods — confectionery,  pastry,  and  the  like — and  the  diabetic  some- 
times has  an  inordinate  craving  for  bread,  which  so  far  possesses 
him  as  to  cause  a  resort  to  any  subterfuge  to  obtain  it. 

In  disordered  mental  conditions,  hysteria,  hypochondriasis,  mel- 
ancholia, and  in  the  peculiar  periods  of  puberty,  pregnancy,  and  the 
menopause,  cravings  for  wholly  injurious  articles  may  occur.  Such 
patients  have  been  known  to  eat  chalk,  or  sour  food,  or  consume 
large  quantities  of  salt,  sodium  bicarbonate,  etc. 

With  the  exception  of  chronic  alcoholism — if  alcohol  be  regarded 
as  a  food  as  well  as  stimulant — there  is  no  distinct  food  "  habit,"  in 
the  sense  that  any  particular  food  is  apt  to  be  long  eaten  to  an  in- 
jurious excess.  Those  articles  of  diet  which  are  oftenest  abused  are 
condiments  and  confectionery. 

VARIETY  IN  DIET. 

Monotony  of  diet  is  not  incompatible  with  maintenance  of  life, 
and  even  of  health,  when  the  food  is  restricted  to  two  or  three  arti- 
cles only,  but  for  the  reasons  given  in  discussing  the  force  value  of 
different  foods  (page  7)  there  is  no  single  food,  not  even  milk,  which 
will  support  man  in  ordinary  health  and  vigour  for  long.  There  are 
many  primitive  races  and  tribes  of  man  who  live  comfortably  upon  a 
diet  so  restricted  that  it  would  soon  prove  unbearable  for  a  European 
or  an  American.  Much,  therefore,  depends  upon  custom,  and  no 
doubt  upon  heredity.  The  Hindu  eats  boiled  rice  and  ghee,  or 
melted  butter,  and  the  low-caste  Chinese  eats  rice  to  the  almost,  but 
not  complete,  exclusion  of  other  food;  the  Eskimo  lives  upon  one  or 
two  kinds  of  meat  or  fish,  and  a  little  fat ;  and  the  Congo  native  sub- 
sists chiefly  upon  the  plantain.  The  Central  American  Indian  lives 
almost  entirely  upon  maize,  and  some  of  the  Polynesians  eat  bread- 
fruit alone  for  two  thirds  of  the  year.  The  roving  Indian  of  the 
North  American  plains  originally  subsisted  all  winter  upon  a  diet  of 
salt  meat,  and  the  Scotch  peasants  formerly  lived  for  six  days  in  the 
week  upon  oatmeal  porridge. 

Such  a  monotony  of  diet  is,  however,  usually  a  question  of  en- 


3o6 


FOOD   DIGESTIOlSf. 


vironment  and  not  of  choice.  The  carnivorous  Eskimo  enjoys 
canned  vegetables  when  they  are  offered  to  him,  and  the  vegetarian 
African  native  gorges  himself  with  meat  when  he  can  obtain  it.  As 
a  rule,  the  more  civilised  the  tribe  of  man  the  greater  is  the  variety 
of  his  diet,  and  once  accustomed  to  variety,  it  is  very  difficult  to  sub- 
sist upon  a  too  restricted  regimen.  It  is  the  ability  to  subsist  upon  a 
variety  of  foods  which  makes  it  possible  for  man  to  adapt  himself  so 
well  to  his  environment  when  he  migrates  from  one  extreme  of  cli- 
mate to  another. 

This  adaptation  is  also  possible  because  the  elementary  foods 
possess  general  nutritive  properties  for  all  the  organs  of  the  body, 
rather  than  special  value  for  individual  structures;  for  example, 
there  is  no  "  brain  food  "  in  distinction  from  food  which  nourishes 
other  organs  as  well. 

An  ideally  perfect  food  combination  if  made  upon  purely  theo' 
retical  considerations  of  the  needs  of  the  body  for  just  so  much  al- 
bumin, fat,  starch,  sugar,  salts,  and  water  would  be  a  compound 
which  in  a  very  short  time  would  become  too  monotonous  and  wea- 
risome to  be  eaten.  Even  the  domestic  animals  are  kept  in  better 
condition  by  occasional  slight  changes  in  diet — such,  for  instance,  as 
are  afforded  by  change  of  pasturage  or  the  variety  which  the  season 
of  the  year  produces  in  their  natural  food ;  and  it  is  well  known  that 
the  flavour  of  the  meat  of  fish  and  wild  animals  depends  upon  the 
nature  of  their  diet.  For  example,  canvasback  and  redhead  ducks 
are  much  more  palatable  while  feeding  upon  the  wild  celery  plant 
■than  when  eating  other  food,  domestic  turkeys  and  capons  improve 
when  fed  upon  grain,  swine  flesh  is  made  better  by  feeding  the  ani- 
mal with  corn  than  with  skimmed  milk,  and  salmon  and  shad  acquire 
a  more  delicate  flavour  when  feeding  in  fresh-water  rivers. 

Among  some  peoples  the  variety  of  food  is  considerably  restricted 
by  religious  observances,  custom,  and  associations.  For  instance, 
there  is  the  Buddhist  prohibition  of  meat  and  the  Jewish  prohibi- 
tion of  swine  flesh.  When  a  variety  in  food  cannot  be  secured  the 
desired  effect  in  stimulating  the  appetite  and  digestive  secretions 
may  be  obtained  by  altering  the  methods  of  cooking  and  by  modi- 
fying the  taste  and  odour  of  food.  On  the  other  hand,  too  great 
variety,  as  well  as  too  elaborate  cooking,  becomes  equally  tiresome. 
Those  who  eat  constantly  at  restaurants  and  large  hotels,  where  the 
table  is  greatly  diversified,  often  find  that  a  change  to  a  simpler  home 
table  agrees  with  them  better. 

Woodruff  attributes  the  decrease  in  drunkenness  in  the  past  few 
years  in  the  United  States  army  to  the  advantages  accruing  from  a 
much  greater  variety  in  diet  since  fresh  vegetables  were  made  a  part 
of  the  ration,  and  since  by  a  system  of  exchange  the  soldier  has  been 
enabled  to  barter  an  excess  of  common  ration  food  for  a  few  articles- 


THE   NERVOUS   SYSTEM   AND   DIGESTION. 


307 


of  luxury.  He  also  says:  "Variety  is  necessary  in  the  army  for 
another  reason  :  When  the  diet  is  very  simple  there  is  apt  to  be 
constipation,  and  in  the  field  this  condition  is  sometimes  quite  marked. 
It  is  recognised  by  physicians  that  chronic  constipation  cannot  be 
properly  treated  with  drugs,  and  it  must  be  rectified  by  diet.  The 
field  ration,  if  possible,  should  overcome  this  tendency  to  constipa- 
tion. Sluggishness  of  the  bowels  quite  commonly  goes  along  with 
discontent,  homesickness  among  soldiers,  and  in  such  conditions  the 
soldier  is  not  a  reliable  fighter — he  is  easily  beaten." 


THE   NERVOUS  SYSTEM   AND   DIGESTION. 

The  influence  of  the  nervous  system  on  digestion  is  very  com- 
plex. In  a  general  way,  the  peripheral  nerves  may  affect  the  digest- 
ive process  (a)  through  the  circulation,  {/>)  through  motion,  (c) 
through  glandular  action.  The  nerves  chiefly  concerned  in  these 
processes  are  the  branches  of  the  sympathetic  system  and  the  vagus. 
The  latter,  through  its  association  with  the  cardiac,  vasomotor,  and 
respiratory  centres  in  the  medulla  oblongata,  places  the  vital  func- 
tions of  the  body  in  very  intimate  connection  with  food  stimulation 
acting  through  the  branches  of  the  nerve  in  the  alimentary  canal. 

(a)  Action  through  the  Circulation. — The  nerves  influence 
digestion  through  the  circulation  by  their  vasomotor  control,  regu- 
lating the  calibre  of  the  vessels  and  quantity  of  blood  supplied 
to  the  walls  of  the  alimentary  canal,  the  local  blood  pressure,  and 
the  consequent  rate  of  absorption. 

{^)  Action  through  Motion. — The  nerves  influence  the  move- 
ments of  the  entire  alimentary  canal,  either  accelerating  or  inhibit- 
ing them,  thus  controlling  the  propulsion  of  the  food,  its  admixture 
with,  secretions,  and  its  contact  with  absorbing  surfaces. 

(c)  Action  through  the  Glands.— The  nerve  supply  of  the 
digestive  glands  is  distributed  to  their  blood  vessels,  and  also  prob- 
ably to  some  extent  to  the  cells  of  the  gland  parenchyma.  This 
latter  distribution  is  not  always  demonstrable  histologically  in  man, 
but  the  influence  is  unquestionable. 

Under  normal  conditions,  the  nerves  act  mainly  in  connection 
with  the  digestion  through  reflex  stimulation  produced  by  mechan- 
cal  irritation  of  food  and  by  the  chemical  irritation  of  its  different 
ingredients  as  they  undergo  absorption.  But,  in  addition,  nerve  cur- 
rents from  the  central  nervous  system  or  from  a  remote  peripheral 
origin  may  interfere  with  the  normal  nerve  functions.  Every  one  is 
familiar  with  examples  of  acute  indigestion  produced  by  fatigue  of 
the  nervous  system,  undue  mental  excitement,  emotion,  etc.  For 
any  given  phase  of  digestion,  disturbance  of  normal  nerve  function 
will  retard  the  process  more  in  its  earlier  stages  by  checking  or  alter- 


^q3  food  digestion. 

ing  gland  secretion.  In  its  later  stages  the  effect  of  the  nervous 
system  will  be  more  pronounced  in  controlling  or  inhibiting  absorp- 
tion. Overstimulation  of  the  local  nerves  of  the  alimentary  tract 
may  excite  an  increased  watery  secretion  and  exaggerate  peristaltic 
movement  of  the  intestines,  thereby  hastening  the  passage  of  the 
food  through  them  before  there  is  time  for  digestion  or  absorption, 
and  giving  rise  to  diarrhoea. 

CIRCULATION  AND  DIGESTION. 

The  influence  of  the  circulatory  system  upon  digestion  appears 
in  the  composition  of  the  blood  and  in  i^s  rate  of  supply  to  the  diges- 
tive glands.  Vigorous  active  circulation  accompanies  good  diges- 
tion and  maintains  a  normal  local  reaction  and  temperature,  and 
feeble,  sluggish  circulation  produces  local  congestion  of  the  viscera 
and  interferes  with  gland  secretion  and  absorption.  When  the 
nerves  of  the  salivary  glands  are  experimentally  stimulated  in  ani- 
mals by  an  electric  current  the  blood  vessels  are  altered  in  calibre. 
If  the  chorda-tympani  nerve  is  stimulated  the  vessels  are  dilated  and 
the  rapidity  of  the  blood  flow  is  accelerated  so  that  the  venous  blood 
issuing  from  the  gland  is  of  a  red  arterial  hue,  it  not  having  lin- 
gered long  enough  to  undergo  the  ordinary  changes  in  regard  to 
its  gases.  The  salivary  secretion  becomes  watery  and  contains  a 
smaller  percentage  of  solids. 

On  the  other  hand,  when  the  sympathetic  nerves  are  stimulated 
exactly  the  reverse  occurs.  Hence  the  blood  supply  is  shown  to 
alter  the  digestive  power  of  a  secretion  by  modifying  its  compo- 
sition. 

Blood  which  is  impoverished  in  composition,  watery,  anaemic,  or 
deficient  in  albuminous  ingredients,  will  furnish  poor  materials  for 
the  manufacture  of  the  digestive  secretions,  and,  further,  the  muscu- 
lar walls  of  the  alimentary  canal  will  suffer  from  malnutrition  and 
peristaltic  action  will  be  diminished. 

TEMPERATURE  AND  DIGESTION. 

Both  the  external  temperature  and  the  internal  body  heat  in- 
fluence digestive  processes.  The  effect  upon  the  system  of  the 
temperature  of  food  and  drink  is  also  a  matter  of  important  consid- 
eration. 

Hot  food  and  drinks  in  cold  weather,  cold  food  and  beverages 
in  hot  weather,  are  instinctively  resorted  to  by  almost  every  one, 
although  this  is,  no  doubt,  as  much  due  to  mental  association  and, 
perhaps,  a  temporary  agreeable  sensation  of  the  temperature  in 
swallowing  as  it  is  to  any  decided  influence  exerted  over  the  body 
temperature. 


TEMPERATURE  AND   DIGESTION. 


309 


Sudden  modifications  in  the  external  temperature  of  either  exces- 
sive heat  or  cold  react  upon  the  circulation,  respiration,  and  the 
nervous  system  in  a  variety  of  ways  and  indirectly  affect  the  digest- 
ive apparatus.  The  shock  of  sudden  or,  more  particularly,  of  con- 
tinued exposure  to  cold  over  the  entire  surface  of  the  body  tends  to 
constrict  the  peripheral  blood  vessels  and  produce  congestion  of  the 
visceral  vessels,  modifying  secretion  and  absorption  in  consequence. 
A  local  application  of  heat  and  of  cold  over  the  abdominal  wall  dur- 
ing activity  of  the  digestive  organs  has  but  limited  influence.  Pa- 
tients wearing  a  Leiter  coil  over  the  abdomen  through  which  ice 
water  is  continually  passed  for  many  hours  do  not  necessarily  suffer 
from  retarded  digestion,  nor  ao  those  who  are  having  poultices  con- 
tinuously applied  to  the  abdomen.  In  a  series  of  experiments  which 
I  have  recently  made  to  determine  the  extent  of  heat  penetration 
through  the  abdominal  wall  it  has  been  shown  that  the  application 
of  heat  or  of  cold  of  such  extremes  as  can  be  borne  without  discom- 
fort has  little  or  no  influence  on  the  circulation  in  the  stomach  or 
the  intestines  or  upon  the  temperature  of  those  organs  so  long  as 
the  subcutaneous  circulation  is  vigorous.  This  is  owing  to  the 
rapid  neutralisation  of  the  heat  or  cold  applied  externally  by  the 
constantly  changing  layer  of  blood  flowing  beneath  the  surface.  In 
dogs,  a  poultice  of  140°  F.  or  an  ice  coil  with  water  at  34°  F.  placed 
over  one  side  of  the  abdominal  wall  does  not  raise  the  temperature 
of  a  long-stemmed  thermometer  more  than  a  quarter  of  a  degree 
when  slipped  beneath  the  abdominal  wall  through  a  perforation  or 
held  immediately  below  the  poultice  or  coil.  If,  however,  the  ani- 
mal be  killed,  circulation  ceases,  and  the  temperature  of  the  ther- 
mometer will  immediately  be  affected  to  the  extent  of  fifteen  or 
twenty  degrees.  It  is  doubtful,  therefore,  whether  enfeebled  diges- 
tion can  be  much  influenced  by  the  local  application  of  warmth  over 
the  abdominal  wall.  Many  persons,  however,  who  have  a  tendency 
to  intestinal  indigestion  find  it  both  agreeable  and  salutary  to  wear 
continuously  a  broad  flannel  bandage  about  the  abdomen  to  favour 
uniformity  in  temperature  and  prevent  the  liability  of  taking  cold. 

It  is  incompatible  with  life  that  the  variations  of  body  tempera- 
ture between  the  highest  fever  and  the  lowest  depression  should 
exceed  the  limits  of  temperature  at  which  digestion  is  known  to  pro- 
ceed when  artificially  conducted,  so  that  these  alterations  do  not  of 
themselves  alone  destroy  digestive  power  in  the  stomach.  The  lat- 
ter is  usually  diminished  or  lost  during  fever,  but  this  may  be  owing 
more  to  disturbances  of  the  circulatory  and  nervous  systems  than  to 
increased  warmth  of  the  stomach. 

Efforts  to  raise  or  lower  the  local  temperature  in  the  stomach 
during  digestion  by  swallowing,  respectively,  hot  watftr  or  pounded 
ice  are  not  productive  of  very  striking  results. 


^jQ  ;FOOD  DIGESTICWSr. 

It  is  customary,  and  no  doubt  best,  to  administer  stimulants -hot 
in  collapse  from  any  cause. 

Wunderlich,  Fotkergill,  and  others  have  laid  considerable  stress 
upon  the  antipyretic  value  of  giving  all  fluids  very  cold  in  fevers, 
but  I  have  yet  to  see  any  effect  upon  genuine  pyrexia,  as,  for  example, 
in  typhoid  fever,  depending  upon  whether  milk  or  other  fluids  were 
administered  very  hot  or  iced.  I  often  prescribe  hot  boiled  milk  in 
such  cases  if  patients  prefer  it,  and  have  taken  it  so  myself  without 
any  appreciable  influence  upon  the  natural  course  of  the  fever. 

It  is  a  popular  belief  that  rich  wines  and  oils  are  "  heating  "  foods, 
and,  conversely,  "  cooling  drinks  "  have  long  been  used  in  fevers,  but 
the  use  of  iced  fluids  and  of  cracked  ice  itself  for  relief  of  thirst  in 
fevers  is  of  comparatively  recent  date.  It  followed  the  extended 
introduction  of  the  clinical  thermometer,  and  to  this  day  one  oc- 
casionally meets  with  opposition  from  mothers  to  giving  a  child  with 
high  fever  anything  really  cold. 

Hot  fluids  drunk  also  favour  perspiration,  and  sometimes  aid  ex- 
pectoration, but  this  is  because  they  are  promptly  absorbed  and 
added  to  the  volume  of  the  blood,  not  because  they  contribute  many 
heat  units  to  the  body.  Winternitz  endeavoured  to  show  by  sphyg- 
mograms  that  the  imbibition  of  cold  fluids  increases  arterial  tension, 
and  that  of  hot  fluids  lessens  it.  This  may  be  true,  but  the  sphyg- 
mograph  is  not  at  all  a  reliable  instrument,  and  certainly  the  clinical 
application  of  this  rule  is  not  capable  of  substantiation,  although  in 
giving  hot-air  baths  to  promote  perspiration  in  Bright's  disease  hot 
drinks  are  of  undoubted  service. 

With  practice  one  may  learn  to  swallow  water  which  is  uncom^ 
fortably  hot  to  the  touch — at  a  temperature  of  115°  or  120°  F.  It 
has  been  swallowed  at  even  132°  F.  The  drinking  of  very  hot  water 
before  meals  aids  in  cleansing  the  mucous  membrane  in  cases  of 
gastric  catarrh  and  acts  as  a  diuretic.  The  rate  of  local  digestion 
in  the  stomach  is  comparatively  little  influenced  by  swallowing  either 
hot  fluids,  such  as  soups  or  broths,  or  hot  solid  foods,  and  similarly 
it  is  not  much  retarded  by  taking  such  substances  very  cold,  provided 
in  each  case  they  are  swallowed  very  slowly.  Some  food  is  more 
digestible  when  eaten  hot  than  cold,  but  with  other  food  the  reverse 
is  true.  In  either  case  it  is  not  so  much  because  of  the  warming  or 
cooling  of  the  stomach,  but  because  of  the  physical  condition  of  the 
food.  For  example,  some  persons  who  cannot  digest  hot  mutton 
fat  can  take  it  cold  because  it  becomes  friable  and  mixes  better 
with  other  food.  Some  persons  with  very  sensitive  stomachs  cannot 
take  the  fat  of  cold  butter  spread  upon  bread,  but  can  digest  it  if 
melted  thoroughly  into  hot  toast,  which  subdivides  the  fat  particles 
and  keeps  them  from  fusion.  Hot  boiled  ham  is  more  indigestible 
than  cold  ham  for  many  persons.     Hot  milk  may  be  more  digestible 


TEMPERATURE   AND   DIGESTION.  3II 

for  invalids  than  iced  milk,  yet  the  latter  may  be  better  borne  if 
vomiting  be  present.  Much  must  depend  upon  habit  and  individual 
peculiarities.  One  may  begin  a  dinner  with  iced  raw  oysters,  then  take 
hot  soup,  and  later  conclude  the  meal  with  ice  cream,  followed  by  hot 
coffee,  and  yet  throughout,  the  temperature  of  the  stomach  contents 
does  not  vary  so  much  as  half  a  degree,  because  the  warm  blood 
circulating  so  rapidly  and  abundantly  within  its  walls  and  those  of 
the  oesophagus  maintains  the  necessary  normal  average  most  favour- 
able to  digestion.  Hot  food  is  cooled  and  cold  food  is  warmed  in 
swallowing,  and  it  may  be  said  the  hotter  or  the  colder  it  is,  the  less 
likely  it  is  to  modify  the  rate  of  gastric  digestion,  for  these  extremes 
of  temperature  necessitate  slow  swallowing.  Swallowing  several 
tumblerfuls  of  iced  water  in  quick  succession  does  cool  the  stomach 
and  inhibit  digestion  by  local  reduction  of  temperature,  and  also  by 
shock  to  the  gastric  nerves;  but  even  this  effect  is  less  than  is  com- 
monly supposed.  There  are  about  fourteen  pounds  of  blood  in  the 
body,  having  an  average  temperature  of  very  nearly  100°  F.,  all  of 
which  in  turn  keeps  circulating  through  the  digestive  organs,  and  a 
single  tumblerful  of  iced  water  poured  into  such  a  volume  of  warm 
fluid  would  not  lower  the  temperature  of  the  whole  very  much.  This 
is  why  swallowing  pounded  ice  is  of  so  little  avail  to  control  gastric 
haemorrhage,  and  much  less  pulmonary  haemorrhage,  although  it  may 
relieve  nausea  somewhat.  In  support  of  these  statements  are  the 
results  of  many  experiments  which  I  have  made  upon  patients  un- 
dergoing treatment  by  lavage,  to  whom  I  have  given  fluids  at  dif- 
ferent temperatures,  which  were  immediately  siphoned  out  of  the 
stomach,  and  tested  for  heat  loss  or  gain.  Two  tumblers  of  ice 
water  may  be  slowly  swallowed,  and  if  promptly  siphoned  out  again 
the  temperature  of  the  fluid  will  be  found  to  have  risen  in  five  min- 
utes to  fully  95°  F. 

The  question  has  often  been  raised  as  to  whether  the  body  tem- 
perature can  be  permanently  affected  by  alterations  in  the  quality 
of  the  diet.  It  may  be  definitely  stated  that  so  long  as  the  diet  is 
abundant  and  nutritious  it  makes  no  difference  whether  man  is 
carnivorous,  a  vegetarian,  or  lives  upon  mixed  diet.  Insufficient 
food  and  starvation  or  inanition  from  improper  food,  it  is  well 
known,  reduce  the  body  temperature  to  from  one  to  three  or  more 
degrees  below  normal.     Excess  of  alcohol  also  reduces  it. 

Improper  and  indigestible  food  may  cause  temporary  rise  in  tem- 
perature, but  this  is  usually  caused  by  more  or  less  gastritis  or 
gastro-enteritis,  and  is  therefore  independent  of  normal  considera- 
tions. The  total  daily  variation  in  body  temperature  normally  pro- 
duced by  the  ingestion  of  food  does  not  commonly  exceed  '/,  °  ¥., 
but  it  may  reach  1°  F.  The  vegetarian  rabbit  has  as  high  a  tem- 
perature as  a  dog  fed  upon  animal  food  alone.     The  grass-eating 


3»2 


FOOD   DIGESTION. 


COW  has  a  temperature  two  or  three  degrees  above  man's  and  quite 
equal  to  that  of  many  strictly  carnivorous  animals.  The  graminiv- 
orous pigeon  has  a  temperature  as  high  as  that  of  the  fish-eating 
gull.  No  deductions  can  therefore  be  made  in  regard  to  any  per- 
manent influence  of  diet  upon  normal  body  temperature  in  healthy 
animals  or  in  man. 

The  loss  of  body  heat  consequent  upon  starvation  and  inanition 
will  be  discussed  under  those  headings. 

EXERCISE  AND   DIGESTION. 

The  influence  of  muscular  exercise  upon  digestion  is  practically 
exemplified  by  every  one's  personal  experience.  Violent  exercise, 
even  by  those  of  robust  constitution,  taken  immediately  after  the 
ingestion  of  food  almost  invariably  retards  the  process  if  it  does 
not  produce  acute  dyspeptic  symptoms,  and  even  vomiting.  This  is 
due  mainly  to  the  modification  in  the  distribution  of  the  blood, 
which  during  active  exercise  passes  in  large  amount  to  the  periphery 
of  the  body,  and  in  much  less  quantity  to  the  abdominal  organs. 
There  are  also  increased  products  of  waste  matter  formed  during 
muscular  activity  which  circulate  in  the  blood,  and  it  is  possible, 
though  it  cannot  be  definitely  asserted,  that  they  may  temporarily 
interfere  with  the  digestive  secretions.  Young  children  between  the 
ages  of  four  or  five  and  ten  or  twelve  suffer  much  less  from  the 
influence  upon  digestion  of  violent  exercise  than  do  adults.  It  is  a 
common  experience  to  see  children  romping  and  playing  violent 
games  immediately  after  eating  without  necessarily  provoking  in- 
digestion— a  procedure  which  would  be  very  disastrous  to  adults. 
On  the  other  hand,  exercise  has  a  very  important  relation  to  diges- 
tion when  taken  at  proper  times  and  in  right  amount.  This  influence 
is  to  be  attributed  rather  to  the  combined  effect  upon  the  circulation 
and  respiration  and  general  functional  activity  of  the  tissues  which 
promotes  their  nutrition  than  to  any  special  local  action  on  the 
stomach  or  intestines.  Exercise  of  a  certain  kind  compresses  or 
shakes  the  liver  in  such  a  manner  as  to  favour  the  elimination  of 
bile  from  it  and  increase  its  functional  activity.  For  this  reason 
horseback  ridmg  is  unquestionably  the  most  useful  form  of  exercise 
for  many  varieties  of  dyspepsia  and  so-called  "  biliousness."  Mus- 
cular fatigue  following  activity  retards  digestion  very  much,  prob- 
ably for  the  reason  above  suggested  in  regard  to  accumulation  of 
waste  matter  as  a  result  of  exercise. 

Moderate  exercise  may  often  be  advantageously  taken  in  the 
morning  on  rising  for  ten  or  fifteen  minutes  in  order  to  get  into  a 
good  perspiration  before  taking  a  cold  bath.  Such  exercise  with 
dumb  bells,  Indian  clubs,  or  weights  with  pulleys  does  not  harm  the 


REST   AND   SLEEP   AND   DIGESTION. 


313 


appetite,  and  for  some  persons  it  is  invigorating  and  beneficial. 
Stronger  exercise,  such  as  bicycle  riding  or  taking  long  walks  before 
breakfast,  is  not  to  be  recommended  unless  the  individual  has  been 
greatly  overfed  the  night  before.  In  the  early  morning  hours,  with 
an  empty  stomach,  exposure  to  the  influence  of  cold  and  damp,  or 
possibly  to  infectious  diseases,  is  believed  to  be  greater  than  at  other 
hours  in  the  day.  Physicians  visiting  cases  of  infectious  diseases  do 
well  to  go  only  at  a  time  of  day  when  they  have  recently  taken  a 
full  meal  and  when  they  are  not  suffering  from  extreme  fatigue. 

Men  differ  greatly  in  the  amount  of  exercise  which  they  find 
necessary  to  keep  them  in  good  health  and  maintain  a  normal  ap- 
petite. To  keep  a  really  vigorous  man  in  the  best  bodily  condition 
he  should  take  daily  exercise  amounting  to  one  hundred  and  fifty  foot 
tons  of  work,  or  an  equivalent  of  a  walk  on  a  level  of  about  nine 
miles ;  but  very  few  are  able  to  accomplish  this  excepting  day 
labourers. 

The  influence  of  food  upon  muscular  activity  has  been  lately 
studied  by  Hodge,  who  reported  some  preliminary  results  at  a  meet- 
ing of  the  American  Physiological  Society,  December  28,  1894.  He 
has  constructed  a  movable  cage  so  arranged  that  any  movements  of 
the  animal  which  it  contains  are  communicated  to  the  cage  itself, 
and  through  it  to  a  recording  tambour  and  kymographion.  In  this 
manner  the  restless  activity  of  the  hungry  animal  seeking  for  food 
about  its  cage  is  recorded,  as  well  as  the  indolence  produced  by  a 
satisfying  fatty  diet  and  the  stimulating  effect  of  nitrogenous  food. 
For  example,  he  demonstrated  that  a  mouse  well  fed  on  corn  meal 
alone  may  be  active  but  a  few  minutes  in  the  day,  whereas  the  same 
animal  fed  upon  meat  and  cream  alone  will  exercise  for  ten  hours 
out  of  the  twenty-four.  This  is  no  doubt  due  to  combined  effects 
of  the  influence  of  the  feeling  of  satiety,  exhilaration,  varying  func- 
tional activity  of  different  organs  of  digestion,  and  of  the  circulation 
and  nervous  system.  It  is  to  be  hoped  that  future  investigations 
will  differentiate  more  clearly  between  these  factors. 

REST  AND  SLEEP  AND  DIGESTION. 

The  custom  of  spending  half  an  hour  in  making  a  leisurely  toilet 
for  dinner  is  beneficial  in  giving  the  rest  to  mind  and  body  which 
puts  the  latter  into  the  most  favourable  conditions.  Dyspeptics 
and  persons  suffering  from  an  irritable  or  feeble  digestive  system 
can  often  derive  much  benefit  by  observing  the  rule  of  not  eating 
when  suffering  from  bodily  or  mental  fatigue.  They  should  lie  down 
from  half  an  hour  to  one  hour  and  quietly  rest  before  each  meal, 
which  may  then  be  digested  in  comfort.  Muscular  fatigue  and  over- 
exertion demand  food  for  the  replenishment  of  waste  material,  but 


314  FOOD   DIGESTION. 

the  immediate  digestive  process  is  much  facilitated  by  an  intervening 
period  of  rest.  It  is  often  advisable  for  them  to  rest  (but  not  sleep) 
for  a  similar  time  after  meals.  The  practice  of  sipping  hot  coffee 
after  dinner  and  of  smoking  a  cigar  is  conducive  to  the  rest  which 
should  be  taken,  whenever  possible,  after  the  ingestion  of  a  heavy 
meal. 

Sleep  is  often  affected  by  the  amount  of  food  taken.  Overeating, 
with  lack  of  physical  exercise  combined  with  sedentary  habits  and 
brain  work,  is  very  apt  to  produce  sleepiness. 

Sleep  in  Relation  to  Meals. — During  profound  sleep  the  differ- 
ent functions  of  the  body  are  all  more  or  less  reduced  in  activity. 
The  rate  of  circulation  and  respiration  becomes  slower,  and  gland 
secretion  and  digestive  processes  are  retarded.  For  this  reason, 
after  eating  a  heavy  meal  at  night,  it  is  unwise  to  retire  for  two  or 
three  hours  until  the  stage  of  gastric  digestion  is  in  part  completed. 
It  is  true  that  many  of  the  lower  animals,  particularly  the  carnivo- 
rous, who  eat  very  frequently,  are  accustomed  to  lie  down  and  sleep 
immediately  after  taking  their  food,  but  their  conditions  in  so  many 
ways  differ  from  those  of  man  that  but  little  is  to  be  gained  by  a  com- 
parison with  them,  and  their  sleep  is  usually  light  until  digestion  is 
accomplished.  On  the  other  hand,  in  man,  if  profound  sleep  follows 
the  eating  of  a  heavy  meal,  it  is  very  apt  to  be  disturbed.  A  large 
volume  of  blood  is  kept  in  the  abdominal  vessels  during  digestion, 
and  the  cerebral  circulation  must  be  modified  in  consequence.  It  is 
possible  also  that  the  various  products  of  nutrition  which  are  being 
absorbed  into  the  blood  may  act  in  stimulating  the  central  nervous 
system  in  peculiar  ways.  Such  sleep  is  restless,  and  is  disturbed  by 
dreams  and  nightmares,  and  even  feverishness. 

On  the  other  hand,  a  light  doze,  in  cases  of  exhaustion  and  for 
the  aged,  taken  for  half  an  hour  after  dinner,  does  certainly  no  harm, 
and  may  promote  digestion  by  allowing  more  blood  to  be  diverted 
to  the  digestive  organs,  none  being  required  for  other  activities. 

Persons  whose  health  is  below  the  average  on  account  of  disor- 
ders of  digestion  and  assimilation  not  infrequently  find  that  they  be- 
come very  sleepy  after  eating,  more  particularly  after  eating  a  heavy 
meal  at  noon;  this  condition  is  sometimes  very  annoying,  and  al- 
ways indicates  a  lack  of  balance  between  the  income  and  output  of 
energy,  which  must  be  regulated  by  proper  attention  to  diet  and  ex- 
ercise. Usually  in  such  cases  the  difficulty  consists  in  habitually  eat- 
ing more  food  than  the  system  can  appropriate,  and  cleansing  the 
body  through  the  emunctories,  with  a  temporary  reduction  in  the 
quantity  of  food  eaten,  will  remove  it.  In  other  cases  the  trouble 
arises  from  the  exhaustion  of  the  nervous  system,  which  is  unable  to 
properly  conduct  two  functions  at  once — that  is,  to  regulate  diges- 
tion and  at  the  same  time  exercise  the  mind.     Obviously,  in  such 


REST  AND   SLEEP  AND   DIGESTION.  315 

cases,  rest  and  tonic  treatment  are  indicated.  The  food  should  be 
given  more  often,  but  in  small  amount. 

In  England  the  custom  is  very  prevalent  among  some  classes  of 
people  outside  of  the  larger  cities  of  taking  four  meals  a  day.  A 
breakfast  at  about  eight  o'clock  and  dinner  from  one  to  two,  and  a 
heavy  tea — that  is,  a  lunch  with  tea  and  some  solid  food — be- 
tween five  and  six,  which  is  followed  by  supper  from  eight  to  nine. 
This  practice  is  well  adapted  for  some  individuals,  especially  young, 
growing  children  at  school  (see  Diet  in  Schools),  but  older  children 
are  apt  to  overeat  if  they  follow  such  a  custom.  An  interval  of 
from  one  and  a  half  to  two  hours  should  elapse  between  eating  supper 
and  retiring,  and  from  two  to  three  hours  between  dinner  and  bed- 
time if  the  alimentary  canal  is  too  empty  ;  sleep  will  be  retarded  on 
this  account,  and  the  earlier  stages  of  hunger  before  great  exhaus- 
tion has  occurred  may  be  accompanied  by  restlessness  and  insomnia. 
A  very  little  food  taken  into  the  stomach  under  these  conditions  will 
often  produce  sleep  promptly.  The  aged,  whose  systems  are  sus- 
ceptible to  slight  changes  in  their  condition  or  environment,  are 
very  apt  to  become  sleepy  after  their  meals,  and  they  find  it  to 
their  advantage  to  take  a  brief  nap  after  dinner  :  but  this  sleep  is 
not  usually  profound,  and  if  it  is  too  prolonged  it  indicates  ex- 
haustion, which  should  be  met  by  more  careful  attention  to  the  diet 
and  stimulation. 

Hunger  produces  wakefulness  and  restlessness,  and  starvation 
may  cause  persistent  insomnia.  Going  to  bed  late  without  dinner 
or  supper  results  in  restlessness  and  insomnia,  which  may  often  be 
cured  by  taking  a  glass  of  hot  milk,  or  a  cup  of  chocolate  and 
some  light  farinaceous  article,  or  a  light  sandwich  and  a  bottle  of 
beer.  In  all  ordinary  cases  of  insomnia  it  is  well  to  see  what  help 
can  be  got  from  diet  and  regular  habits  before  resorting  to  hypnotics 
(see  Insomnia,  page  582). 

In  some  diseases,  notably  diphtheria,  it  becomes  a  grave  question 
between  nourishment  and  sleep  as  to  which  is  the  more  important. 
Vigorous  local  measures  may  be  needed  to  control  the  spread  of  the 
membrane  in  the  throat,  necessitating  half-hourly  applications  day 
and  night,  which  of  course  interrupt  sleep;  and  yet  the  patient  may 
need  to  be  wakened  for  such  applications,  and  the  giving  of  nourish- 
ment and  stimulants  as  well.  Sleep  is  often  more  needful  than  food, 
and  it  is  the  duty  of  the  physician  to  see  that  there  is  a  proper 
balance  between  them.  In  general,  in  exhausting  disease,  protracted 
typhoid  or  other  fevers,  etc.,  nourishment  must  be  given  once  in  two 
hours  day  and  night ;  but  if  the  patient  does  not  fall  asleep  readily 
at  night  after  being  aroused  for  food,  the  intervals  may  be  made 
three-hourly,  and  as  strength  returns,  four-hourly.  In  such  cases  it 
is  sometimes  well  to  relax  the  rule,  and  give  the  patient  one  good 


-jg  FOOD  DIGESTION. 

night's  rest  of  five  hours  without  awakening  him  for  food;  but  the 
degree  of  exhaustion  and  need  of  cardiac  stimulants  must  be  the 
guide  in  each  separate  case. 

MENTAL  EMOTION  AND  DIGESTION. 

Strong  mental  emotion,  such  as  fright,  terror,  or  excessive  excite- 
ment of  almost  any  kind,  inhibits  the  digestive  functions,  especially 
in  the  stomach,  but  also  in  the  intestines.  Such  emotion  may  be 
accompanied  by  vascular  disturbances  which  will  react  upon  the 
digestive  organs,  and  in  addition  there  seems  to  be  a  diversion  of 
nerve  currents  from  their  proper  course.  Pleasurable  emotions, 
however,  affect  digestion  favourably,  and  the  expression  "  laugh  and 
grow  fat "  is  certainly  not  without  physiological  basis. 

Hufeland  wrote  that  "  laughter  is  one  of  the  greatest  helps  to 
digestion  with  which  I  am  acquainted,  and  the  custom  prevalent 
among  our  forefathers  of  exciting  it  at  table  by  jesters  and  buffoons 
was  founded  upon  true  medical  principles." 

Prolonged  anxiety  and  worry,  in  almost  every  instance,  result  in 
more  or  less  gastric  indigestion  and  malassimilation,  so  that,  al- 
though the  appetite  may  remain  good,  nervous  dyspepsia,  constipa- 
tion, and  loss  of  weight  result. 

FOOD  IN  THE  MOUTH. 

The  proper  care  of  the  mouth  in  relation  to  diet  is  an  important 
subject  which  is  frequently  overlooked.  In  patients  who  are  unable, 
from  weakness  or  the  prostration  of  fever,  to  use  solid  food  or  to 
cleanse  the  mouth  themselves,  lack  of  movement  in  the  tongue  and 
buccal  muscles  prevents  proper  cleansing  of  the  teeth,  and  particles 
of  food  accumulate  about  the  gums.  In  extreme  weakness  of  the 
facial  muscles  the  jaw  drops  and  mouth  breathing  results.  The  air 
passing  through  the  mouth  evaporates  the  moisture  present  and 
gives  rise  to  dryness  of  the  tongue,  which  may  become  so  extreme 
as  to  interfere  with  deglutition  and  articulation. 

In  such  cases  the  mouth  should  be  frequently  moistened  by  the 
nurse  and  swabbed  out  by  some  antiseptic,  such  as  a  saturated  solu- 
tion of  boric  acid  or  diluted  Listerine.  This  topic  will  be  more  fully 
treated  under  the  heading  Dietetic  Treatment  of  Typhoid  Fever. 

Food  which  is  allowed  to  collect  in  the  cavities  of  decayed  teeth 
favours  the  development  of  bacteria,  which  on  being  swallowed  may 
become  a  cause  of  dyspepsia  by  exciting  malfermentation  in  the 
stomach,  especially  of  milk.  Much  bacterial  filth  accumulates  be- 
neath artificial  teeth  which  are  not  frequently  cleansed.- 

Imperfect  or  painful  teeth,  or  swollen  gums,  interfere  with  the 


FOOD   IN   THE   STOMACH. 


317 


proper  mastication  of  food,  and  when  such  conditions  are  present 
care  should  be  exercised  that  all  food  eaten  be  soft  and  bland.  This 
applies  particularly  to  young  children,  very  old  persons,  and  the  in- 
sane, who  are  incompetent  to  take  care  of  their  own  mouths. 

The  digestion  of  non-nitrogenous  food  begins  in  the  mouth,  and 
depends  upon  the  activity  of  the  salivary  ferment  ptyalin,  which  con- 
verts starches  into  dextrin  and  maltose.  In  health  this  action  is 
prompt  and  vigorous,  and  much  of  the  starchy  food  is  digested  in 
the  mouth,  in  its  transit  along  the  oesophagus,  and  also  in  the  stom- 
ach, until  the  gastric  juice  becomes  so  acid  as  to  check  the  process, 
for  ptyalin  is  most  active  upon  the  alkaline  side  of  the  neutral  point, 
and  strong  acidity  inhibits  its  power.  Chittenden  has  demonstrated 
that  after  neutralising  saliva,  ptyalin  fermentation  proceeds  well  in 
the  presence  of  0.005  P^r  cent  of  hydrochloric  acid,  but  stops  with 
0.025  P^''  cent.  Dufresne  is  responsible  for  the  statement  that 
ptyalin  recovers  its  activity  in  the  alkaline  intestine,  but  that  dias- 
tase is  completely  destroyed  by  the  gastric  juice. 

In  feeble  and  ill-nourished  persons  the  salivary  digestion  becomes 
much  impaired,  and  consequently  their  farinaceous  food  should  be 
partially  dextrinised  artificially  by  diastase  or  by  prolonged  cooking. 

An  acid  reaction  in  the  mouth  may  be  present  because  of  fer- 
mentation, not  because  the  saliva  itself  is  acid.  In  rheumatism  the 
saliva  is  very  often  acid.  This  reaction  causes  a  sensation  of  dry- 
ness, lessens  the  taste  for  food,  and  gives  rise  to  thirst.  Saliva 
which  is  rich  in  cells  and  mucus  is  too  viscid,  and  does  not  moisten 
the  food  properly  during  mastication.  When  salivation  is  present, 
the  ptyalin  becomes  too  dilute  to  have  any  digestive  action  upon 
starchy  foods.  If  swallowed,  the  too  abundant  saliva  carries  much 
air  into  the  stomach;  and  if  it  is  alkaline,  it  neutralises  the  gastric 
juice.  A  dry  diet  (see  Dry  Diet)  will  sometimes  improve  this  unde- 
sirable condition. 


FOOD    IN    THE    STOMACH. 

Much  controversy  has  arisen  over  the  question  as  to  how  far  the 
stomach  performs  the  essential  work  of  digestion,  and  how  far  the 
intestine  is  responsible  for  it.  Some  writers  argue  that  the  stomach 
is  a  comparatively  useless  organ  except  as  a  receptacle,  and  that  the 
small  intestine,  with  the  different  juices  which  are  poured  into  it,  is 
abundantly  capable  of  doing  alone  the  digestive  work  for  the  entire 
body.  Several  experimenters  have  successfully  excised  the  stomachs 
of  dogs,  and  after  the  oesophagus  had  been  united  to  the  intestine 
the  animals  digested  their  food  apparently  as  well  as  before.  They 
were  even  able  to  digest  decomposing  meat  without  the  aid  of  the 
antiseptic  action  of  the  gastric  juice. 


.jg  FOOD  dig;e>stion. 

Of  recent  years  more  careful  analysis  has  shown  that  the  digest- 
ive products  formed  from  the  food  in  the  stomach  are  by  no  means 
as  complete  in  all  cases  as  was  at  first  supposed.  The  only  really 
important  action  of  this  organ  consists  in  digesting  a  single  class  of 
foods — namely,  proteids — and  this  process  is  not  always  finished,' 
whereas  the  intestine  digests  not  only  proteids,  but  fats,  starches, 
and  sugars. 

The  stomach  serves  to  warm  and  macerate  all  the  food,  so  that 
it  relieves  the  small  intestine  of  much  preliminary  work  of  this  kind. 

Gastric  digestion  is  hindered  by  either  acids  or  alkalies  used  in 
excess,  by  metallic  salts,  strong  alcohol,  and  by  regurgitation  of  bile 
from  the  intestine. 

Quantity  of  Gastric  Juice  and  other  Digestive  Fluids. 

No  reliable  estimates  of  the  exact  quantity  of  gastric  juice,  or, 
in  fact,  of  any  of  the  digestive  fluids,  are  obtainable.  At  best,  such 
estimates  vary  greatly  according  to  different  authorities.  An  abun- 
dant secretion  is  not  necessarily  an  active  one  in  ferment  or  acid, 
and  the  constant  reabsorption  of  the  water  makes  it  quite  impossible 
to  say  how  much  fluid  has  been  secreted,  for  if  the  digestive  juices 
be  drained  off  and  measured,  the  natural  conditions  are  disturbed  by 
the  process. 

Bile  or  pancreatic  fluid  allowed  to  drain  off  constantly  through 
a  fistula  is  found  to  soon  become  altered  in  quality  and  weakened  in 
digestive  power. 

The  estimates  which  have  been  made  of  the  total  quantity  of  the 
digestive  fluids  secreted  per  diem  extend  all  the  way  from  three  or 
four  quarts  to  three  gallons ! 

The  quantity  of  gastric  juice  is  sometimes  estimated  by  the 
amount  of  pepsin  and  acid  which  outside  of  the  body  are  re- 
quired to  digest  a  measured  bulk  of  food.  As  an  illustration  of 
an  extreme  estimate,  that  of  Letheby  as  to  the  relative  quantity  of 
secretion  of  the  gastric  and  pancreatic  juices  may  be  given.  It  is  : 
Gastric  juice,  14. ii  pounds;  pancreatic  juice,  0.44  pound.  Such 
an  estimate  is  wholly  fallacious,  for  the  pancreatic  juice  is  far  more 
active  than  the  gastric  juice — it  has  ten  times  the  work  to  do — and 
the  pancreatic  gland  cells  outnumber  the  gastric  cells. 

Moreover,  there  are  but  fourteen  pounds  of  blood  in  the  entire 
body,  and  it  does  not  seem  probable  that  a  quantity  of  secretion 
equal  to  the  whole  volume  of  blood  should  be  formed  by  a  single 
organ  like  the  stomach.  It  would  require  very  rapid  reabsorption 
from  the  stomach  not  to  have  it  remain  full  all  the  time. 


FOOD   IN    THE   STOMACH. 


Secretion  of  the  Gastric  Juice. 


319 


When  food  enters  the  stomach  it  immediately  excites  the  secre- 
tion of  the  gastric  juice.  This  it  does  at  first  through  mechanical 
action,  either  upon  the  nerves  or  the  cells  of  the  gastric  tubules 
themselves.  The  purely  physical  character  of  the  food  which  is 
taken  into  the  stomach  will  therefore,  to  some  extent,  affect  the  rate 
of  secretion  as  well  as  the  composition  of  the  gastric  juice,  and 
foods  are  often  spoken  of  as  being  either  bland  or  irritating.  The 
former  are  those  which  are  soft  or  in  a  fine  state  of  subdivision,  such 
as  well-cooked  farinaceous  articles.  The  latter  are  the  coarser  forms 
of  food  and  condiments,  especially  pepper,  mustard,  curry,  pickles, 
etc.,  which  have  a  more  specific  influence  in  increasing  the  flow  of 
juice.  This  is  probably  due  to  reflex  action  through  the  nerves  of 
the  gastric  mucous  membrane. 

The  gastric  juice  is  secreted  more  abundantly  in  response  to  the 
chemical  stimulus  of  some  foods  than  others,  as,  for  example,  sodium 
chloride  and  carbonate  and  alcohol  when  taken  in  moderate  dilution. 
If,  however,  they  are  taken  to  excess  they  cause  derangement  of  the 
gastric  function,  and  congestion  ensues  with  secretion  of  a  neutral 
or  alkaline  mucoid  juice  instead  of  the  true  acid  secretion. 

Haidenhain  has  observed  that  the  mechanical  pressure  of  food 
against  the  stomach  wall  may  be  comparatively  local  and  circum- 
scribed, whereas  the  chemical  stimulation  of  the  food  as  soon  as  it 
begins  to  be  felt,  causes  abundant  secretion  from  the  whole  surface 
of  the  stomach,  which  becomes  red  and  turgescent  from  increased 
vascularity. 

The  flow  of  juice  commences  almost  immediately  after  the  food  has 
entered  the  stomach,  and  it  continues  to  be  secreted  in  varying  quan- 
tity for  two  or  three  hours.  After  this  period  the  secretion  gradu- 
ally diminishes.  If  the  food  has  not  been  properly  digested  within 
a  limit  of  three  and  a  half  hours,  it  may  fail  to  pass  on  into  the  intes- 
tine, and  while  remaining  in  the  stomach  it  undergoes  various  pro- 
cesses of  malfermentation  which  are  wholly  different  from  the  normal. 
These  processes  will  be  more  fully  discussed  under  the  headings  of 
the  several  forms  of  dyspepsia.  By  examining  the  interior  of  the 
human  stomach  when  a  fistula  has  been  made,  it  appears  that  if  the 
organ  is  empty,  merely  irritating  the  mucous  membrane  by  rubbing 
its  surface  gently  with  a  glass  rod  provokes  the  secretion  of  juice, 
which  first  appears  in  little  clear  drops  at  the  site  of  irritation. 
These  gradually  coalesce  and  form  tiny  rivulets  which  run  over  the 
mucous  surface  to  the  most  dependent  portion  of  the  stomach.  At 
the  same  time  the  mucous  membrane  becomes  somewhat  congested 
and  of  a  pinkish  hue,  owing  to  the  greater  quantity  of  blood  which 
circulates  through  it. 
23 


S20 


FOOD   DIGESTION. 


Hydrochloric  Acid. 


Hydrochloric  acid  exists  in  the  human  gastric  juice  in  the  aver- 
age proportion  of  0.2  per  cent.  Experimentally  it  is  found  that  the 
best  proteolytic  digestion  results  with  hydrochloric  acid  in  strength 
between  o.i  and  0.2  per  cent.  The  acidity  is  reduced  upon  a  vege- 
table diet. 

The  acid  is  secreted  during  active  digestion  but  not  at  other 
times.  It  is  often  diminished  in  quantity,  and  much  less  often  it 
may  be  abnormally  increased.  Its  action  upon  proteid  foods  like 
egg  albumen,  blood  fibrin,  and  meat,  is  to  cause  them  to  swell  and 
become  somewhat  translucent.  It  contributes  the  necessary  acid 
reaction  in  which  the  ferment  pepsin  causes  solution  of  these  and 
other  proteids  and  converts  them  into  albumoses. 

The  quantity  of  free  acid  obtainable  from  the  stomach  is  not  great 
when  much  proteid  food  has  been  eaten,  although  its  secretion  may 
have  been  considerable.  The  secretion  of  the  acid  begins  shortly 
after  the  ingestion  of  food,  and  reaches  a  maximum  within  about  an 
hour.  After  an  hour  or  two  longer,  according  to  the  nature  and 
quantity  of  the  food  present,  it  gradually  lessens  and  finally  ceases. 

According  to  the  views  of  some  writers,'the  first  acid  formed  m 
the  stomach  is  lactic  acid,  which  joins  the  alkali  of  chlorides  in  the 
blood,  and  liberates  chlorine  to  form  hydrochloric  acid.  Maly  has 
advocated  the  theory  that  the  hydrochloric  acid  was  formed  from 
the  action  of  phosphates  in  the  blood  serum,  splitting  up  the  chlo- 
rides so  that  the  highly  diffusible  hydrochloric  acid  passes  readily 
out  upon  the  free  surface. 

Roberts  furnishes  the  following  table  illustrating  the  effect  of 
varying  quantities  of  hydrochloric  acid  on  the  speed  of  peptic  di- 
gestion : 

2  grammes  beef-fibre  ;    i  c.  c.  glycerin  extract   of  pepsin  ;   varying   proportions   of 
hydrochloric  acid  ;  water  to  100  c.  c 

Proportion  of  dry  HCI  in  the  Time  in  which  digestion 

digesting  mixture.  was  completed. 

0.05  per  cent 500  minutes,  almost  no  digestion. 

o .  08    "       "    200       " 

0.1      "       "    130       " 

0.15    "       "    115 

0.2     "       "    100       " 

03      "       "    115        " 

0.4     "       "    160 

0.6     "       "    350  minutes,  embarrassed. 

The  acid  has  an  antiseptic  influence,  preventing  the  decomposi- 
tion of  food,  and  even  checking  it  if  already  begun.  It  is  also  be- 
lieved to  possess. an  influence  over  the  formation  of  pepsin.  Briicke 
claims,  contrary  to  many  observers,  that  the  acid  of  the  stomach 


FOOD   IN   THE   STOMACH.  32 1 

makes  starch  more  soluble,  and  that  much  of  it  is  also  converted  by 
lactic-acid  fermentation  in  the  stomach  into  erythrodextrin. 

Pepsin.— According  to  Chittenden,  pepsin  is  a  hydrolytic  ferment 
which  is  found  in  the  cells  of  the  tubules  of  the  gastric  mucous 
membrane,  chiefly  near  the  cardiac  portion.  It  exists  in  these  cells 
in  an  antecedent  form,  or  as  a  granular  ''proenzyme,"  which  is  called 
pepsinogen  or  propepsin,  and  the  agent  which  is  believed  to  convert 
the  propepsin  into  true  pepsin,  the  active  ferment,  is  hydrochloric 
acid.  This  theory  assigns  a  new  function  to  this  acid.  Lactic  and 
acetic  acids  derived  from  food  possess  the  same  power  in  lesser 
degree. 

Like  the  other  digestive  ferments,  pepsin  belongs  to  the  class  of 
colloid  or  non-crystallisable,  indiffusible  substances. 

Pepsin  digests  coagulated  egg  albumen  even  better  than  fibrin, 
gluten,  casein,  myosin,  and  gelatin,  and  hence  this  substance  is  com- 
monly employed  in  making  quantitative  tests  of  the  relative  digestive 
power  of  different  preparations  of  the  ferment.  The  standard  of  the 
United  States  Pharmacopoeia  requires  that  pepsin  shall  dissolve 
three  thousand  times  its  own  weight  of  coagulated  disintegrated 
egg  albumen.  "The  rapidity  of  digestion  is  augmented  only  up  to  a 
certain  point  by  increase  in  the  quantity  of  pepsin,  but  beyond  this 
limit  it  has  no  accelerating  influence — no  influence  at  all,  in  fact. 

Pepsin  reaches  its  maximum  activity  at  a  temperature  considerably 
higher  than  that  of  the  body — namely,  130°  F.  Its  action  is  sus- 
pended below  40°  F.,  and  destroyed  between  160°  and  170"  F, 

The  secretion  of  both  pepsin  and  the  rennet  ferment  or  rennin 
which  is  often  associated  with  it  seems  to  rise  and  fall  with  that  of 
hydrochloric  acid,  but  this  is  not  always  the  case. 

Rennin  has  been  described  on  page  61. 

Aibumo^es,  Peptones. — The  final  product  of  food  digestion  as 
accomplished  by  pepsin  with  the  hydrochloric  acid  of  the  gastric 
juice  is  peptone.  Kiihne  showed  that  peptone  is  seldom,  if  ever, 
pure  in  the  stomach,  but  the  substance  produced  is  a  mixture  of  true 
peptone  with  proteoses  or  albumoses,  which  have  reactions  that  in 
many  respects  are  similar.  The  albumoses  are  more  highly  diffusible 
than  peptones.  Undoubtedly  both  peptones  and  albumoses  are 
formed  during  digestion,  and  both  may  be  absorbed. 

Albumoses,  like  peptone,  give  a  violet  colour  when  added  to  a 
dilute  Fehling  solution  of  copper  sulphate,  and  on  boiling  with  nitric 
acid  they  exhibit  a  yellow  colour  and  a  precipitate  which  alternately 
falls  on  cooling  and  disappears  upon  warming.  The  albumoses  may 
be  separated  from  peptones  by  complete  precipitation  by  saturation 
in  aqueous  solution  with  sulphate  of  ammonium.  Bauer  states  it  as 
his  belief  (Dietary  of  the  Sick)  "  that  the  peptones  do  fulfil  in  the 
organism  all  the  functions  of  the  albuminous  bodies,  since  they  are 


222  FOOD   DIGESTION. 

again  turned  into  coagulable  albumin  " ;  but  dissolved  albuminates 
are  not  necessarily  converted  into  peptones  before  they  are  capable 
of  absorption  (Voit  and  Bauer). 

Politzer,  Gerlach,  and  others  have  demonstrated  experimentally 
that  albumoses  can  support  nutrition  and  even  cause  gain  in  weight 
when  given  alone  and  free  from  peptones,  and  Hildebrandt  found 
that  the  nitrogen  of  albumoses  artificially  fed  to  animals  was  utilised 
in  the  nutrition  of  the  body  to  an  even  greater  degree  than  the  pep- 
tones of  meat. 

An  excess  of  peptones  overworks  the  liver  and  produces,  on 
reaching  the  general  vascular  system,  various  nervous  disorders — 
lithaemia,  gout,  etc. 

Peristalsis. — In  addition  to  exciting  secretion  upon  entering  the 
stomach,  the  food,  at  first  by  mechanical  action  and  subsequently 
possibly  through  chemical  stimulation,  excites  more  or  less  rhythmical 
peristaltic  movement  in  the  muscular  coat  of  the  stomach.  The  ob- 
ject of  this  movement  is  fourfold  :  i.  To  mingle  the  contents  of  the 
food  thoroughly  with  the  gastric  juice.  2.  To  cause  moderate  tritu- 
ration of  the  particles  of  food  which  are  made  to  move  in  currents 
which  proceed  along  the  greater  curvature  and  pass  back  to  the 
cardiac  end  along  the  lesser  curvature.  3.  To  bring  the  food  in 
contact  successively  with  different  portions  of  the  mucous  membrane, 
and  to  thus  stimulate  it  and  favour  the  absorption  of  such  ingredients 
as  this  division  of  the  alimentary  canal  is  capable  of  taking  up.  4. 
To  favour  the  occasional  emptying  of  a  portion  of  the  contents  of 
the  stomach  into  the  duodenum,  the  movement  at  this  time  being 
accompanied  by  a  relaxation  of  the  pyloric  orifice. 

Peristaltic  action  is  influenced  by  the  nature  and  composition  of 
the  food  ingested,  and  it  may  be  also  stimulated  in  other  ways,  which 
will  be  more  fully  described  in  connection  with  intestinal  peristalsis 
(see  Diarrhoea  and  Constipation),,  for  it  may  be  said  in  general  that 
those  stimuli  which  effect  intestinal  peristalsis  also  influence  this 
peculiar  movement  in  the  stomach. 


DURATION    OF    GASTRIC    DIGESTION    OF    DIFFERENT 

FOODS. 

Bauer  says:  "By  the  digestibility  of  a  food  one  can  obviously 
understand  nothing  more  or  less  than  the  sum  of  the  resistances  that 
it  offers  to  the  action  of  the  gastric  juice." 

The  time  required  for  gastric  digestion  cannot  be  stated  with  ab- 
solute accuracy.  In  general,  the  period  for  the  full  digestion  of  a 
mixed  meal  consisting  of  bread,  meat,  and  vegetables  is  three  and  a 
half  hours,  but  because  some  kinds  of  food  are  thoroughly  digested 
in  the  stomach,  while  others  are  acted  upon  but  little  if  at  all,  the 


DURATION   OF   GASTRIC   DIGESTION   OF   DIFFERENT   FOODS.    323 

preponderance  of  one  or  other  article  of  food  in  a  mixed  diet  may 
affect  somewhat  the  whole  period  of  digestion.  Tables  are  sometimes 
given  in  text-books  upon  physiology  in  which  the  time  required  for 
digestion  of  various  kinds  of  meat  are  stated  in  a  very  definite  and 
arbitrary  manner,  and  we  are  told  perhaps  that  it  requires  fifteen  or 
twenty-five  minutes  longer  to  digest  mutton  than  beef  (see  Digesti- 
bility of  Meats,  page  95).  All  such  statements,  however,  should  be 
received  with  ample  allowance  for  ordinary  variations.  If  one  con- 
siders for  a  moment  the  different  elements  concerned  in  the  process 
of  gastric  digestion,  it  is  obvious  that  the  normal  time  required  for 
complete  digestion  will  vary  constantly,  even  in  the  same  individual 
in  a  state  of  health,  for  it  depends  upon  the  kind  of  food  eaten  as 
well  as  the  following  conditions  :  i.  Its  state  of  subdivision,  its  solu- 
bility, complexity,  and  the  process  of  its  cooking.  2.  The  rapidity 
with  which  it  is  swallowed.  3.  The  thoroughness  with  which  it  is 
masticated.  4.  The  activity  of  the  stomach  at  the  time.  5.  The 
interval  which  has  elapsed  since  the  previous  meal.  6.  The  condi- 
tion of  the  blood  and  nerve  supply  of  the  gastric  glands.  7.  The 
activity  of  peristaltic  movement,  which  may  either  retard  or  hurry 
the  rate  of  emptying  the  stomach.  8.  The  amount  of  fluid  drunk 
with  which  the  gastric  juice  is  diluted.  9.  The  strength  of  the  im- 
portant ingredients  of  this  juice,  its  volume,  and  the  effect  upon  it 
of  food  itself,  neutralising  it  or  not.  10.  The  rate  of  absorption. 
II.  Habit.  12.  Idiosyncrasy.  13.  The  presence  of  excess  of  fat 
or  other  materials  incapable  of  digestion  in  the  stomach.  14.  The 
diversion  of  the  nervous  energy  required  for  digestion  to  other 
functions,  such  as  mental  or  muscular  work. 

Such  statements  are  often  definitely  made  in  articles  upon  die- 
tetics as  that  boiled  mutton  requires  three  hours  for  stomach  diges- 
tion, while  roasted  mutton  requires  three  hours  and  eighteen  minutes ; 
that  raw  oysters  require  two  hours  and  fifty-five  minutes  and  roasted 
oysters  three  hours  and  eleven  minutes;  that  boiled  carrots  require 
three  hours  and  sixteen  minutes,  and  the  like. 

These  figures  may  impress  the  lay  mind  as  being  of  interest  and 
accuracy,  but  when  the  above  considerations  have  been  taken  into 
account,  it  must  be  seen  that  they  are  far  from  reliable.  It  is  impor- 
tant, however,  to  state,  if  possible,  the  approximate  time  required  for 
the  digestion  of  certain  general  classes  of  food,  and  the  following 
estimates  are  probably  as  nearly  correct  as  possible  in  view  of  the 
statements  above  made. 

The  time  required  for  the  complete  digestion  of  meats  cooked 
by  broiling,  roasting,  or  boiling,  is  fully  three  hours  or  three  hours 

and  a  half. 

Gigglberger  found,  as  a  result  of  feeding  patients  with  test  meals 
and  withdrawing  the  stomach  contents  through  a  tube,  that  meat  re- 


224  FOOD   DIGESTION. 

quires  from  two  and  a  half  to  five  and  a  half  hours  for  digestion, 
according  to  its  quality,  method  of  cooking,  etc.  Stewed  meats 
require  less  time  than  roasts. 

Pork  and  very  fat  meat  may  require  four  or  five  or  more  hours 
for  digestion,  and  veal  is  generally  of  slow  digestion,  requiring  at 
least  four  hours.  Fresh  lamb  may  be  digested  in  two  and  a  half 
to  three  hours. 

Chicken,  capon,  and  turkey  may  be  digested  in  from  two  to  two 
and  a  half  hours,  but  the  meat  of  many  of  the  forms  of  wild  birds, 
such  as  ducks,  may  require  four  hours. 

Some  of  the  viscera  of  animals  which  are  eaten  as  food,  such  as 
brains,  tripe,  liver,  and  kidneys,  are  digested  in  less  time — approxi- 
mately two  hours.  Fish  and  shellfish  require  from  two  and  a 
half  to  three  hours  for  their  digestion.  Raw  eggs  are  usually 
digested  in  less  time  than  cooked  ones,  and  they  may  be  ready  for 
absorption  in  two  hours,  whereas  hard-boiled  eggs  require  at  least 
three  and  a  half  hours.  Milk  is  usually  digested  somewhat  sooner 
when  boiled  than  if  raw.  Milk  whey  is  absorbed  from  the  stomach, 
but  the  curds  often  pass  on  into  the  duodenum. 

The  majority  of  the  heavier  vegetables,  such  as  peas,  beans,  corn, 
beets,  turnips,  etc.,  remain  in  the  stomach  for  between  three  and  three 
and  a  half  hours,  but  potatoes,  if  baked  and  mealy,  may  remain  but 
two  and  a  half  hours. 

Raw  vegetables,  such  as  coleslaw  or  raw  cabbage  and  lettuce,  etc., 
may  remain  two  and  half  hours  or  more  in  the  stomach,  and  the  same 
IS  true  of  most  raw  fruits,  such  as  berries,  apples,  pears,  peaches,  etc. 

The  more  digestible  cereals — rice,  sago,  tapioca,  etc. — should 
pass  on  from  the  stomach  within  two  hours. 

Fats  and  oils  taken  alone  may  not  remain  in  the  stomach  but  a 
few  moments. 

Sugars  may,  to  some  extent  at  least,  be  absorbed  from  the 
stomach  wall  in  the  course  of  the  first  hour  of  digestion. 

Since  gastric  juice  is  fairly  constant  in  composition,  its  effect  in 
health  upon  the  duration  of  digestion  of  the  same  kind  of  food 
may  not  vary  in  the  same  individual ;  but  persons  differ  from  one 
another  very  much  in  the  rapidity  of  their  digestive  processes.  In 
some  individuals,  even  in  health,  stomach  digestion  may  be  uni- 
formly an  hour  or  more  slower  than  it  is  in  others.  Variations 
from  the  usual  period  of  digestion  are  almost  always  upon  the  side 
of  its  retardation.  The  quality,  composition,  and  quantity  of  the 
food  all  affect  the  rate  of  gastric  digestion. 

Coarse  food,  badly  cooked  starchy  food,  excess  of  fats,  tough- 
fibred  meats,  unripe  fruits  or  vegetables,  all   retard  digestion,  and" 
may  prove  very  irritant. 

Among  articles  of    diet,  substances  are  sometimes  eaten  which 


DIGESTION   OF   PROTEIDS   IN   THE   STOMACH. 


325 


are  purely  refuse  material,  such  as  the  skin  of  potatoes  and  of  coarse 
fruits,  grape  seeds,  shells,  soft-shell  crabs,  etc. 

They  may  pass  on  unaltered  into  the  intestine  and  cause  diar- 
rhoea, or  they  may  sometimes  linger  for  several  days  and  excite 
reflex  irritation.  I  have  known  undigested  capsules  of  cod-liver  oil 
to  be  retained  in  the  stomach  for  three  or  four  days  before  being 
vomited  (see  Cod-liver  Oil,  page  180). 

The  temperature  of  food  and  drink  affecting  gastric  digestion  is 
discussed  under  the  heading  Temperature  and  Digestion. 

DIGESTION   OF   PROTElt^S   IN  THE  STOMACH. 

The  various  albuminous  foods  are  digested  best,  each  with  a 
different  degree  of  acidity,  and  it  is  probable  that  throughout  a 
meal  the  intensity  of  reaction  of  the  gastric  juice  varies  consider- 
ably, becoming  stronger  as  more  food  is  absorbed  or  more  juice  is 
formed,  or  weaker  as  more  of  it  passes  with  the  chyme  into  the 
pylorus  or  as  it  is  more  diluted  with  additional  food  or  drink. 
In  this  manner  the  different  proteids  are  all  certain  of  a  fair  oppor- 
tunity for  timely  digestion. 

The  products  of  albuminoid  digestion  in  the  stomach  have  been 
carefully  analysed  by  Kiihne  and  Chittenden,  and  are  found  to  suc- 
ceed each  other  in  the  following  order : 

1.  Albuminoids  or  proteio^. 

2.  Syntonin  or  acid  albumin. 

3.  Albumoses  or  proteoses — proto-albumose,  hetero-albumose, 
deutero-albumose. 

The  three  latter  form — 

4.  Peptones. 

Raw  meat  in  the  stomach  turns  grey-brown  and  swells.  It  takes 
longer  to  digest  meat  raw  th^n  when  cooked,  for  the  fibres  are  pene- 
trated less  easily  by  the  gastric  juice.  An  exception  to  this  is  found 
when  the  raw  meat  is  first  scraped  or  made  into  a  pulp.  In  the  di- 
gestion of  meats  Frerichs  found  that  the  connective  tissue  is  first 
broken  down  by  the  gastric  juice,  then  the  sarcolemma,  and  finally 
the  substance  between  the  striae  of  the  muscle  fibres. 

Vegetable  albumin  is  digested  in  the  stomach  in  a  manner  quite 
similar  to  the  digestion  of  animal  proteids. 

Gluten  and  vegetable  casein  are  also  dissolved  by  the  gastric  juice 
when  strongly  acid. 

Gelatin  is  one  of  the  substances  most  easily  dissolved  in  and 
absorbed  from  the  stomach.  It  is  altered  by  the  hydrochloric  acid 
of  the  gastric  juice,  so  that  it  can  no  longer  be  solidified  by  cold. 
If  is  finally  converted  into  diffusible  substances  somewhat  resembling 
peptones,  but  not  identical  with  them. 


326 


FOOD   DIGESTION. 


ABNORMALITIES    OF    GASTRIC    DIGESTION. 


(The  clinical  examination  of  the  stomach  contents  will  be  found  elsewhere  described 
under  that  heading.     See  page  489.) 

Hypersecretion. — -Hypersecretion  of  gastric  juice  gives  rise  to 
thirst,  sour  eructations,  more  or  less  epigastric  distress,  and  it  often 
accompanies  dilatation  of  the  stomach.  The  secretion  may  digest 
proteids  well,  but  carbohydrates  are  ill  borne  in  this  condition,  which 
is  believed  to  be  chiefly  caused  by  some  form  of  neurosis.  An  excess 
of  acid  gastric  juice  passes  on  with  the  chyme  into  the  small  in- 
testine, and  causes  an  acid  reaction  therein,  requiring  more  of  the 
intestinal  digestive  fluids — bile,  pancreatic  juice,  etc. — to  neutralise 
it.  The  saliva  is  often  increased  at  the  same  time,  and  Roberts 
suggests  that  this  may  be  a  provision  of  Nature  to  neutralise  the 
acid  in  the  stomach. 

Hyperacidity. — Hyperacidity,  or  increase  in  the  hydrochloric 
acid  of  the  gastric  juice,  does  not  necessarily  imply  hypersecretion 
of  juice.  Hypersecretion  may  be  abundant,  watery,  and  weak  in 
acid,  or  more  concentrated  with  stronger  acid,  or  normal  in  quantity 
but  with  increased  hydrochloric  acid. 

Hyperacidity  is  not  very  common,  and  is  more  apt  to  be  present 
in  connection  with  gastric  ulcer  than  other  diseases. 

Absence  of  Hydrochloric  Acid. — The  persistent  absence  of 
hydrochloric  acid  from  the  gastric  contents  does  not  absolutely 
indicate  the  presence  of  any  one  disease,  but  rather  that  a  consider- 
able extent  of  the  gastric  mucosa  is  involved,  and,  indeed,  according 
to  Ewald,  it  may  be  absent  in  nervous  dyspepsia  without  organic 
lesion. 

Pyrosis. — Pyrosis,  or  eructation  of  gas  from  the  stomach,  if  it 
occurs  very  soon  after  ingestion  of  food,  is  usually  due  to  lactic- 
acid  fermentation.  Occurring  later,  (Mring  active  digestion,  it  may 
be  due  to  the  same  cause  or  to  hyperacidity  from  excess  of  hydro- 
chloric acid.  The  latter  condition  is  less  common  when  due  to 
lactic  acid ;  the  giving  of  hydrochloric  acid  stops  further  fermenta- 
tion, whereas  sodium  bicarbonate,  although  it  momentarily  neutral- 
ises the  lactic  acid,  soon  produces  an  alkaline  reaction  in  which  the 
further  development  of  the  acid  rapidly  proceeds.  On  the  other 
hand,  pyrosis  due  to  hydrochloric  acid  must  be  checked  by  alkalies. 

FOOD    IN    THE    INTESTINE. 

After  preliminary  maceration  under  the  conditions  of  the  moisture, 
warmth,  and  motion  in  the  stomach,  and  after  partial  digestion  there, 
the  food,  mixed  with  gastric  juice,  passes  in  a  pultaceous  mass, 
known  as  chyme,  into  the  duodenum.     Here  the  physical  conditions 


FOOD   IN   THE   INTESTINE.  327 

are  almost  identical  with  those  found  in  the  stomach,  but  the  chem- 
ical composition  of  the  new  digestive  fluids — namely,  the  bile  and 
pancreatic  and  intestinal  juices — is  alkaline,  and  a  number  of  new 
ferments  complete  the  solution  and  digestion  of  the  food. 

The  starches  which  were  but  partially  digested  by  the  saliva  are 
converted  into  dextrin,  maltose,  and  glucose  by  a  diastatic  ferment — 
amylopsin — contained  in  the  pancreatic  juice.  Cane  sugar  is  con- 
verted by  the  intestinal  juice  into  glucose,  any  proteids  which  have 
been  but  partially  digested  in  the  stomach  are  completely  converted 
into  proteoses  and  peptones  by  the  proteolytic  ferment  trypsin  of 
the  pancreatic  juice,  and  the  fats  are  emulsified  and  saponified  by 
the  combined  action  of  the  bile  and  a  pancreatic  ferment. 

Pancreatic  juice  is  the  most  active  and  comprehensive  digesting 
fluid  of  the  body.  It  is  not  only  much  stronger  than  the  gastric 
juice  in  its  action  upon  proteids,  being  able  to  form  peptones  with 
fewer  intermediate  products,  but  it  possesses  the  distinct  advantage 
that  it  also  digests  fats  and  carbohydrates  by  a  ferment,  called  steap- 
sin,  which  acts  in  either  acid  or  alkaline  media. 

Its  amylolytic  power  is  stronger  than  that  of  the  saliva,  for  it 
digests  the  raw  starch  and  cellulose  which  is  eaten  in  such  vegetables 
as  celery,  lettuce,  or  radishes,  and  in  fruits  like  the  apple. 

The  ultimate  products  of  trypsin  digestion  are  antipeptones  and 
hemipeptones.  The  ferment  acts  best  in  a  fluid  medium  rendered 
alkaline  by  from  0-5  to  i  per  cent  sodium  carbonate.  It  also  digests 
proteids  energetically  in  a  neutral  medium,  but  free  acid  soon  de- 
stroys it.  Chittenden  has  shown  that  combined  acids  do  not  neces- 
sarily put  a  stop  to  trypsin  proteolysis. 

The  bile  plays  several  roles  in  intestinal  digestion,  but  its  chief 
action  is  in  aiding  the  emulsion  of  fats,  described  below.  It  can 
accomplish  the  absorption  of  fats  even  in  the  absence  of  pancreatic 
juice.  When  bile  is  absent  tfce  fatty  food  may  decompose  in  the  in- 
testine and  develop  gases  and  foul  odours. 

Voit  says  that  the  white  colour  of  icteroid  stools  is  dependent 
rather  upon  the  presence  of  undigested  fat  than  the  absence  of  bile, 
for  with  a  meat  instead  of  a  milk  diet  they  may  still  be  of  a  dark 
colour. 

When  a  biliary  fistula  is  made  in  dogs  and  the  bile  is  drained  away, 
they  emaciate  and  have  a  ravenous  appetite  if  fed  upon  meats  and 
fats,  but  not  if  fed  upon  carbohydrates  (Voit). 

The  quantity  of  bile  secreted  is  increased  by  a  nitrogenous  diet, 
and  diminished  upon«an  exclusive  fat  diet  (Uffelmann). 

Vegetable  foods  colour  the  bile  green  ;  animal  foods  make  it  yel- 
low or  orange. 

Bile  is  often  said  to  prevent  putrefactive  changes  in  the  food  in 
the  intestine.     It  is  not,  however,  an  antiseptic  substance,  for,  unlike 


328 


FOOD   DIGESTION. 


the  gastric  juice,  it  easily  undergoes  decomposition,  and  the  influence 
attributed  to  it  is  due  rather  to  its  promotion  of  peristalsis,  thereby- 
keeping  the  intestinal  contents  moving  and  preventing  stagnation 
and  putrefaction. 

The  Digestion  of  Fats. — When  fat  is  cooked  in  the  food,  a 
good  deal  of  it  is  converted  into  rancid  fat — i.  e.,  fat  containing  free 
fatty  acids.  In  the  mouth  the  fatty  food  is  unaltered,  unless  it  be  in 
the  form  of  adipose  tissue,  when  the  process  of  mastication  breaks  it 
down  and  liberates  some  of  the  fat  globules,  which  are  melted  by  the 
natural  warmth.  If  eaten  in  the  form  of  oil  or  butter,  with  starchy 
or  vegetable  food,  the  fat  coats  the  particles  of  food  in  the  mouth. 
Bread  thus  mingled  with  butter  is  less  apt  to  form  a  large  and  too 
tenacious  bolus. 

In  the  stomach  the  fat  remains  unaltered,  and  when  the  semifluid 
chyme  begins  to  flow  into  the  intestine  it  passes  in  with  it.  The 
connective-tissue  elements  of  fatty  meats,  etc.,  are  dissolved  away 
and  digested  like  other  proteids  by  the  gastric  juice. 

In  the  intestine  the  fat  is  subjected  to  a  double  process  of  emul- 
sification  and  saponification,  which  is  accomplished  by  the  combined 
action  of  the  bile  and  pancreatic  juice.  The  latter  splits  fats  into 
glycerin  and  fatty  acid,  and  this  action  is  favoured  by  the  admix- 
ture with  bile,  which  simultaneously  occurs  in  the  duodenum.  Ac- 
cording to  Rachford,  the  fat-splitting  power  of  pancreatic  juice  is 
more  than  trebled  by  bile,  although  the  latter  has  no  fat-splitting 
influence  of  its  own.  He  also  declares  that  the  presence  of  hydro- 
chloric acid  which  has  just  entered  the  upper  duodenum  with  the 
chyle,  like  the  bile,  still  further  aids  the  pancreatic  action  upon  fats, 
as  four  to  one. 

It  is  held  by  the  majority  of  authorities  that  pancreatic  juice  also 
contains  an  emulsifying  ferment,  steapsin,  and  that  the  free  fatty 
acid  above  described  splits  up  the  sedium  bile  salts  and  liberates 
their  sodium,  which  unites  with  a  portion  of  the  free  fatty  acid,  form- 
ing a  soap.  The  soap  coats  the  droplets  of  emulsified  fat  with  a  thin 
film  (like  a  soap  bubble)  and  prevents  them  from  coalescing  again. 
The  emulsion  is  then  absorbed  by  the  lacteals. 

Opposed  to  this  theory  is  the  one  ably  advocated  by  Rachford — 
namely,  that  the  hydrochloric  acid  and  bile  in  the  duodenum  not 
only  can  prevent  the  formation  of  emulsions,  but  can  destroy  those 
already  formed  by  redissolving  their  coatings.  Hence  he  argues  that 
in  the  duodenum  fats  are  split,  but  not  emulsified,  and  that  they  pass 
further  on  and  enter  the  jejunum,  where  they  encounter  the  intesti- 
nal juice,  containing  about  0.25  per  cent  of  sodium  carbonate.  This 
salt  prevents  further  fat-splitting,  and  at  the  same  time  emulsifies 
the  fats. 

It  is,  however,  not  a  necessary  part  of  the  theory  of  digestion  of 


ARTIFICIAL   DIGESTION. 


329 


fatty  food  that  the  fat  must  all  be  emulsified.  No  doubt  a  large  part 
of  it  is  absorbed  more  directly  or  as  a  soap  without  emulsification. 

Extracts  of  both  the  liver  and  spleen  have  been  said  to  favour 
the  absorption  of  fats  by  emulsification. 

Undigested  food  reaches  the  intestines  under  the  following  con- 
ditions :  (a)  When  too  much  food  is  eaten,  (d)  when  gastric  digestion 
is  imperfect,  (c)  when  the  food  is  bad. 

Intestinal  Gases. — During  the  digestion  of  certain  foods  in  the 
intestine  more  or  less  gas  is  evolved.  The  gas,  by  distending  the 
walls  of  the  gut,  serves  the  purpose  of  keeping  them  from  agglutinat- 
ing, and  thereby  facilitates  the  free  movement  and  intermingling  of 
the  digestive  fluids  and  food,  and  the  absorption  of  the  latter. 

Ruge  has  published  the  following  table  of  the  percentage  of  gas 
evolved  by  several  different  kinds  of  foods : 


MILK. 

MEAT. 

PEAS   OK    BEANS. 

Food. 

I. 

2. 

I. 

2. 

3- 

I. 

2. 

3- 

CO,.... 

H 

CH«.... 
N, 

16.8 

43-3 
0.9 

38.3 

9.9 
54-2 

36.7 

13-6 
30 

37-4 
45-9 

12.4 
2.1 

27.5 
57-8 

8.4 

0.7 

26.4 

64.4 

34.0 

2.3 

44.5 

19. I 

38.4 

49-3 
10.6 

21.0 
4.0 

55.9 
18.9 

ARTIFICIAL    DIGESTION. 

To  physiologists  we  are  indebted  for  the  discovery  and  develop- 
ment of  the  scientific  preparation  of  digestive  ferments  or  enzymes 
and  the  predigestion  of  food  outside  of  the  body.  The  composition 
of  the  various  digestive  ferments  and  their  action  in  general  have 
been  understood  for  a  long  time,  but  it  is  only  withirf  the  last  two  or 
three  decades  that  the  use  of  these  organic  bodies  has  been  made 
practicable  on  a  large  scale  for  rendering  food  more  digestible  or 
assimilable  by  invalids,  and  the  whole  question  of  artificial  digestion 
of  foods  is  one  which  is  absorbing  more  and  more  careful  attention 
and  thorough  study.  The  subject  may  be  said  to  be  yet  in  its  in- 
fancy, and  it  is  highly  probable  that  the  extensive  researches  which 
are  being  conducted  by  so  many  investigators  at  the  present  day 
will  yield  even  more  practical  and  important  results  than  those  al- 
ready attained.  The  use  of  predigested  food  at  present  forms  an 
indispensable  adjunct  to  the  treatment  of  a  large  number  of  serious 
diseases,  both  acute  and  chronic,  especially  those  which  concern  the 
alimentary  canal,  and  the  methods  of  infant  feeding  have  been  prac- 
tically reorganised  by  it. 

The  different  ferments  which  can  be  used  for  increasing  the  ac- 
tivity of  digestion  within  the  body  or  for  partially  digested  foods 
outside  of  the  body  are  principally  diastase,  pepsin,  and  extracts  of 
pancreatic  juice,  which  are  usually  called  pancreatin,  and  which  are 


230  FOOD   DIGESTION. 

compounds  of  several  substances.  Besides  these  there  are  several 
vegetable  ferments,  such  as  papain  from  the  American  papaw,  and 
ferments  are  present  in  the  juice  of  the  pineapple,  and  the  century 
plant  or  agave. 

Predigestion  of  Starches. 

There  are  a  variety  of  ferments  and  other  materials  which  have 
the  power  of  converting  starch  into  dextrin  and  sugar.  They  are 
ptyalin  in  the  saliva,  amylopsin  in  the  pancreatic  juice,  diastase,  a 
ferment  in  the  intestinal  juice,  and  the  substances  inulin  and  lichen- 
in.  The  latter  is  obtainable  from  various  lichens,  such  as  Iceland 
moss.     Mucin  and  certain  gums  are  also  amylolytic. 

Of  these  different  ferments,  the  one  which  is  found  to  be  of  most 
practical  service  for  predigestion  is  diastase. 

The  action  of  the  diastase  of  malt  resembles  that  of  the  ptyalin  of 
the  saliva  and  the  amylopsin  of  the  pancreatic  juice,  which  alter 
starches  into  dextrin  and  maltose.  It  is  prepared  in  several  ways, 
as,  for  example,  in  meal  of  malt,  which  may  be  added  to  farinaceous 
foods,  and  in  the  form  of  malt  extracts,  and  various  malted  foods 
(malted  milk,  etc.)  are  sold  for  invalid  use  or  for  infant  feeding. 

In  such  preparations  the  predigestion  of  amylaceous  foods  is 
carried  to  the  extent  of  more  or  less  complete  conversion  of  the 
starch  into  dextrin  and  maltose.  The  diastase  has  no  action  in  the 
stomach  provided  the  acid  gastric  juice  is  being  secreted,  for  it  only 
causes  fermentation  in  a  neutral  or  alkaline  medium  ;  in  fact,  the 
ferment  is  probably  destroyed  before  reaching  the  intestine.  The 
presence  of  alkaline  carbonates  retards  the  action  of  diastase.  In 
early  infancy  the  amylolytic  ferments  of  the  salivary  and  pancreatic 
fluids  are  not  well  developed  and  are  very  meagre  in  quantity.  If  a 
young  child  is  unable  to  digest  milk  for  any  reason,  malted  food 
may  be  temporarily  supplied  in  some  cases,  because  in  it  the  starch 
is  already  more  or  less  completely  digested  and  is  ready  for  absorp- 
tion. In  general,  the  value  of  malted  foods  and  malt  extracts  de- 
pends upon  the  predigested  starch  which  they  contain,  which  fur- 
nishes nutrition,  rather  than  upon  the  action  of  the  diastatic  ferment 
within  the  alimentary  canal. 

Ground  malt  itself  possesses  even  stronger  digestive  action  upon 
starches  than  malt  extracts.  The  latter  contain  the  ferment  dias- 
tase, dextrin,  maltose,  and  a  portion  of  the  salt  aild  some  nitroge- 
nous ingredients  of  barley.  Both  ground  malt  and  malt  extracts 
digest  starches  at  a  moderate  heat,  not  exceeding  150°  F.  There 
are  many  varieties  of  malted  foods,  but  Liebig's  Infant  Food  is  a 
good  illustration  of  this  type  of  food.  It  is  prepared  as  follows  (see 
also  page  131) : 

Mix  a  half  ounce  each  of  ground  malt  and  wheat  flour,  seven 


ARTIFICIAL   DIGESTION. 


331 


and  one  fourth  grains  of  potassium  bicarbonate  with  one  ounce  of 
water  and  five  ounces  of  sweet  cow's  milk.  Warm  slowly  and  stir 
until  thick.  Remove  from  fire,  stirring  for  five  minutes,  replace 
over  fire,  and  remove  when  quite  thick.  As  the  diastase  continues 
to  act  the  mass  will  become  thin  and  sweet.     Boil  and  strain. 

It  contains  gluten  and  albumin  of  flour  and  barley,  besides  dex- 
trin and  maltose. 

The  food  thus  prepared  is  very  nutritious,  for  it  not  only  con- 
tains the  proteid  materials  of  the  milk,  but  those  also  of  the  wheat 
flour  and  malted  barley  (gluten  and  albumin),  as  well  as  the  predi- 
gested  starch.  The  malted  foods  which  are  made  with  desiccated 
milk  and  malted  flour  are  deficient  in  fats,  salt,  and  proteid  material, 
but  the  lack  of  these  substances  can  be  supplied  by  the  addition  to 
the  food,  when  used,  of  cream  and  beef  juice. 

For  manufacturing  malted  foods  the  wheat  or  barley  flour  should 
be  baked  in  order  to  rupture  the  starch  granules  and  make  them 
more  soluble. 

Predigestion  of  Proteids. 

The  digestion  of  proteids  may  be  accomplished  either  within  the 
body  by  prescribing  pepsin  and  hydrochloric  acid,  or  without  the 
body  by  use  of  the  same  agents,  or,  as  it  is  more  often  done  at  pres- 
ent, by  pancreatinisation. 

Pepsin  was  the  first  among  the  digestive  ferments  to  be  isolated 
and  employed  for  artificial  fermentation. 

This  ferment  diff'ers  from  diastase  in  the  fact  that  it  is  capable  of 
continuing  its  digestive  functional  activity  within  the  body,  and  it  is 
therefore  frequently  prescribed  in  cases  of  deficient  gastric  secretion, 
to  be  taken  with  the  meals,  or  immediately  after,  as  a  powder  or  in 
solution.  The  action  of  pepsin  is  confined  to  the  conversion  of 
albuminous  food,  and  it  requires  an  acid  reaction.  It  is  sometimes 
claimed  that  the  continual  administration  of  pepsin  and  dilute  hydro- 
chloric acid  may  weaken  the  stomach  by  doing  the  work  of  that 
organ  while  it  rests ;  but  it  is  difficult  to  see  any  true  ground  for  the 
statement,  for  this  action  in  no  wise  concerns  the  stomach  wall  or  its 
secretion,  but  is  limited  to  the  conversion  of  food  into  more  easily 
soluble  material,  which  increases  the  general  bodily  nutrition,  and 
and  therefore  indirectly  improves  the  stomach  digestion. 

Pepsin  is  destroyed  by  dilute  solutions  of  sodium  carbonate  as 
well  as  by  the  alkaline  pancreatic  intestinal  fluids  and  the  bile.  It 
is  obtained  in  a  number  of  forms  for  use  in  aiding  gastric  digestion, 
such  as  scales,  dry  powder,  pills,  and  solution.  There  is  considerable 
variation  in  the  strength  of  the  preparations,  depending  upon  the 
care  taken  in  their  manufacture  and  differences  in  the  processes  of 
extracting  the  ferment;  but  all  of  them  have  some  digestive  action, 


332 


FOOD   DIGESTION. 


and  they  are  very  serviceable  remedies  for  gastric  indigestion.  A 
comparative  analysis  of  the  relative  digestive  power  of  several  of 
the  more  important  ones  was  made  by  Prof.  Chittenden  and  reported 
in  the  Philadelphia  Medical  News  (February  i6,  1889)  as  follows: 

(i)  Parke,  Davis  &  Co.'s  Pepsinum  Purum  in  Lamellis 100 

(2)  Fairchild's  Pepsin  in  Scales 52 

(3)  Scheffer's  Dry  Pepsin  Concentrated 48 

(4)  Jensen's  Crystal  Pepsin 35 

(5)  Boudault's  Pepsin 14 

(6)  Royal  Chemical  Company's  Pure  Pepsin 9 

Pepsin  should  never  be  given  in  combination  with  an  alkali,  such 
as  sodium  bicarbonate,  excepting  in  cases  of  hypersecretion  of 
hydrochloric  acid  with  scanty  pepsin  formation,  a  decidedly  rare 
form  of  gastric  disorder. 

The  pepsin-secreting  cells  predominate  over  the  acid-forming 
cells  in  the  stomach  so  largely  that  they  are  seldom  destroyed  to 
the  same  degree  as  the  latter,  and  hence  pepsin  is  of  much  less  im- 
portance than  hydrochloric  acid  in  the  treatment  of  both  functional 
and  organic  disease  of  the  stomach.  It  is  a  very  common  practice 
to  prescribe  it  in  tablet  form  without  acid,  but  as  a  rule,  to  which 
there  are  almost  no  exceptions  other  than  that  of  hyperacidity,  in 
those  cases  in  which  the  exhibition  of  pepsin  is  indicated  hydro- 
chloric acid  is  equally  if  not  more  important,  and  they  should  be 
prescribed  together. 

The  pepsin  is  given  in  doses  of  three  to  five  or  ten  grains  imme- 
diately after  meals  when  proteid  food  of  any  kind  has  been  eaten. 
Ten  grains  may  be  added  to  a  pint  of  milk,  but  if  long  continued  in 
excess  of  twenty  grains /^r  diem,  it  may  excite  purgation. 

Pancreatin  is  the  name  given  to  a  complex  fermentative  body 
derived  from  extracting  the  pancreatic  gland.  It  is  obtained  in  the 
form  of  a  dry  powder,  and  also  as  a  solution  or  liquor.  Its  intro- 
duction is  mainly  due  to  the  researches  of  Dr.  William  Roberts,  of- 
England. 

The  extract  made  from  the  pancreatic  gland  is  a  powerful  digest- 
ive agent  and,  on  the  whole,  is  more  serviceable  for  the  predigestion 
of  food  than  any  of  the  other  ferments.  It  contains  both  trypsin 
and  amylopsin.  This  extract  also  emulsifies  fats,  and  it  is  quite 
as  easy,  if  not  easier,  to  obtain  the  pancreatic  extract  than  pepsin, 
and  since  its  action  is  so  powerful  and  varied,  the  majority  of  the 
predigested  food  preparations — the  so-called  "  peptonised  foods  " — 
are  made  with  pancreatin  instead  of  pepsin.  Pancreatin  is  sometimes 
prescribed  by  physicians  for  internal  use,  but  unless  protected  in  a 
keratin-coated  capsule  the  ferments  are  entirely  destroyed  in  the 
stomach  by  the  action  of  the  gastric  juice.  Keratin  is  a  horny  sub- 
stance derived  from  feathers  which  is  not  soluble  in  acid  fluid,  but 


ARTIFICIAL   DIGESTION. 


333 


is  quite  soluble  in  alkaline  media.  Hence  a  capsule  containing  five 
grains  of  pancreatin  coated  over  with  keratin  may  remain  undis- 
solved in  the  stomach  until  gastric  digestion  is  completed,  when  it 
will  pass  into  the  intestine,"  where  the  coating  is  dissolved  and  the 
ferments  act  upon  the  chyle.  It  is  customary  to  add  some  alkali, 
such  as  sodium  bicarbonate,  to  the  pancreatin  in  the  process  of  arti- 
ficial digestion,  although  it  will  also  operate  on  proteid  matter  in  the 
presence  of  a  neutral  reaction.  All  the  products  of  pancreatin  di- 
gestion, as  well  as  the  ferment  derived  from  the  juice  itself,  decom- 
pose if  exposed  for  any  length  of  time  to  the  air.  Pure  meat  pep- 
tones, prepared  either  by  pepsin  and  hydrochloric  acid  or  by  trypsin 
in  alkaline  solution,  are  ready  for  immediate  absorption  and  are 
nutritive,  but  a  very  general  objection  to  their  use  exists  in  the  ex- 
ceedingly disagreeable  odour  and  taste  which  they  possess,  which  to 
many  persons  are  nauseating  and  disgusting.  This  difficulty  is  over- 
come when  peptones  are  used  for  rectal  injection,  for  which  purpose 
they  are  most  valuable.  Efforts  are  often  made  to  disguise  the  disa- 
greeable taste  and  odour  of  beef  peptones  in  various  ways.  When 
obtained  in  solution,  wines  and  aromatic  substances  are  added  to 
them  or  they  are  sometimes  evaporated  to  dryness,  pulverised,  and 
redissolved  in  sherry,  but  the  taste  is  exceedingly  persistent  and  it  is 
often  difficult  or  impossible  to  disguise  it  in  any  manner,  so  that 
patients  will  not  sooner  or  later  object  to  it.  Among  the  principal 
peptones  which  are  used  are  Koch's,  Kemmerich's,  Catillon's  and 
Carnrick's,  Savory  and  Moore's,  and  Benger's.  Some  of  the  pan- 
creatinised  foods  are  strengthened  by  the  addition  of  predigested 
starches  and  sugars.  Some  of  them  constitute  very  good  foods 
for  cases  of  enfeebled  digestion  or  diminished  absorptive  power. 
Among  them  may  be  mentioned  Benger's  Food,  which  is  made 
with  cooked  wheat  meal  and  pancreatic  extract.  The  latter  par- 
tially converts  the  starches  into  malt  and  diastase,  and  when  added 
to  milk  at  the  proper  temperature  for  fermentation,  it  acts  upon  the 
casein  and  converts  it  into  a  soluble  peptone.  Oat  flour  and  lentil 
flour  are  similarly  prepared.  Carnrick's  Infant  Food  is  made  on  the 
same  principle  with  Benger's  Food,  with  wheat  flour,  pancreatin, 
and  milk,  to  which  is  added  a  certain  percentage  of  lactose.  Savory 
and  Moore  prepare  a  concentrated  predigested  milk  and  milk  with 
cocoa,  which  have  an  agreeable  taste  and  considerable  nutrient 
value.     Another  preparation  is  Loeflund's  Peptonised  Kindermilch. 

All  peptonised  or  pancreatinised  foods  are  open  to  the  objection 
that  they  are  much  more  expensive  if  used  for  a  long  time  than  the 
preparations  which  can  be  easily  made  at  the  bedside  by  any  intel- 
ligent person  by  the  use  of  the  simple  pancreatin  extracts.  Among 
these  extracts  are  Benger's  Liquor  Pancreaticus  and  Peptonising 
Powders  and  Fairchild's  Zymine,  which  act  upon  lean  meat  as  well 


224  FOOD   DIGESTION. 

as  milk.  If  complete  peptonisation  is  required,  large  quantities  of 
the  ferment  must  be  used,  and  the  process  should  be  continued  longer 
than  for  a  lesser  degree  of  peptonisation.  One  or  two  drachms  of 
Benger's  Liquor  Pancreaticus  with  fifteen  grains  of  sodium  bicar- 
bonate will  completely  peptonise  half  a  pint  of  milk  in  a  few  min- 
utes if  the  bottle  be  immersed  in  water  which  is  heated,  but  which 
is  not  too  hot  for  the  hand  to  bear.  Roberts's  rule  for  pancreatinised 
milk  gruel  is  quoted  by  Yeo  as  follows:  "A  good  thick  gruel  made 
with  oatmeal  or  other  meal  while  still  boiling  hot  is  added  to  an 
equal  quantity  of  cold  milk.  The  temperature  of  the  mixture  will 
then  be  about  140°  F.  To  a  pint  of  this  mixture  two  or  three  tea- 
spoonfuls  of  Liquor  Pancreaticus  and  twenty  grains  of  bicarbonate 
of  soda  are  added  ;  it  is  kept  at  the  same  temperature  for  about  two 
or  three  hours,  and  then  boiled  for  a  few  minutes  and  strained.  This 
mixture  contains  not  only  the  casein  of  the  milk  peptonised,  but  the 
starch  of  the  material  is  converted  into  sugar  and  its  albuminates 
are  peptonised.  The  bitterness  of  the  peptonised  milk  is  scarcely 
perceptible  in  this  gruel." 

Papoid  is  a  vegetable  ferment  which  is  thus  described  by  Prof. 
Chittenden,  of  Yale  University  : 

"  Extended  study  of  the  reactions  of  the  vegetable  ferment 
papoid  shows  that  it  is  composed  essentially  of  a  mixture  of  vege- 
table globulin,  albumoses  and  peptone,  with  which  is  associated  the 
ferments  characteristic  of  the  preparation. 

"  Papoid,  so  far  as  my  observations  extend,  has  the  power  of 
digesting  to  a  greater  or  less  extent  all  forms  of  proteid  or  albu- 
minous matter,  both  coagulated  and  uncoagulated.  Furthermore, 
papoid  is  peculiar  in  that  its  digestive  power  is  exercised  in  a  neu- 
tral, acid,  and  alkaline  medium. 

"  Papoid  will  act  in  dilute  solutions,  but  the  best  and  character- 
istic action  is  seen  only  when  a  small  volume  of  fluid  is  present. 
In  this  respect  it  differs  very  markedly  from  the  animal  ferment 
pepsin,  and  for  this  reason  any  direct  comparison  of  the  two  fer- 
ments is  practically  impossible,  but  blank  experiments  without 
papoid  [with  acid  and  alkali  as  used  in  these  experiments]  showed 
that  these  reagents  have  in  themselves  only  a  comparatively  light 
solvent  action  on  raw  fibrin." 

After  taking  the  ferment  it  is  found  in  the  stools,  showing  that  it 
is  not  wholly  destroyed  in  the  alimentary  canal. 

It  is  prescribed  in  doses  of  from  one  to  three  grains  after  each 
meal. 

FOOD  ABSORPTION. 

The  absorption  of  food  takes  place  from  the  stomach  to  a  limited 
extent,  to  a  great  degree  from  the  small  intestine,  and  to  a  lesser 


ELIMINATION   OF   FOOD  WASTE. 


335 


degree  from  the  larger  intestine.  The  rectum  is  capable  of  absorb- 
ing enough  predigested  food  to  sustain  life  for  several  weeks  (see 
Food  Enemata).  The  entire  digestive  process  does  not  have  to  be 
completed  before  absorption  begins.  Usually  those  foods  which 
are  first  digested,  or  which  are  administered  in  predigested  form, 
are  first  absorbed. 

The  rate  of  absorption  depends  upon  the  degree  of  digestibility 
of  the  food,  the  extent  of  absorbing  surface  with  which  it  is 
brought  into  contact  by  the  peristaltic  movement,  the  composition 
of  the  blood,  the  relative  pressure  in  the  intestine,  blood  vessels, 
and  lymphatics,  and,  probably  more  than  anything  else,  upon  the 
functional  activity  of  the  cells  covering  the  intestinal  villi.  The 
accompanying  table  shows  the  percentage  of  food  swallowed  which 
is  actually  absorbed  : 


Weight  of  Food. 

Absorbed. 

Residue. 

Of  lOO  parts  of  solids  of  mixed  diet 

89.9 
81.2 
96.9 

II. I 

"           "          albumin 

18.8 

"           "          fats  or  carbohydrates 

31 

ELIMINATION  OF  FOOD  WASTE. 

The  following  data  are  quoted  by  Yeo  : 

"  According  to  Dujardin-Beaumetz,  a  man  loses,  in  connection 
with  the  processes  of  nutrition,  nitrogen,  carbon,  water,  and  salts. 
In  twenty-four  hours  these  losses  [for  an  adult  man  at  moderate 
labor],  on  an  average,  amount  to  20  grammes  (300  grains)  of  nitrogen, 
310  grammes  (4,650  grains)  of  carbon,  30  grammes  (450  grains)  of 
salts,  and  3  litres  (about  6  pints)  of  water.  The  chief  part  of  the 
nitrogen  (14.5  grammes)  passes  away  in  the  urine  in  the  form  of 
urea  and  uric  acid,  and  the  remainder  (5.5  grammes)  in  the  faeces, 
perspiration,  and  mucous  discharges.  Of  the  carbon,  350  grammes 
are  consumed  in  the  lungs,  45  grammes  are  eliminated  by  the  kid- 
neys, and  15  grammes  in  the  other  secretions.  The  water  passes  off 
by  the  skin,  lungs,  kidneys,  and  bowels.  A  man's  food  must  con- 
tain the  elements  necessary  to  repair  these  incessant  losses. 

"The  20  grammes  of  nitrogen  represent  124  grammes  of  dry 
proteid  matters,  and  as  these  contain  64  grammes  of  carbon,  on  sub- 
tracting the  64  grammes  from  the  300  grammes  necessary  for  nutri- 
tion there  remain  236  of  carbon  to  be  derived  from  starch  sub- 
stances or  from  fats." 

When  waste  matter  has  accumulated  in  the  system  its  elmina- 
tion  may  be  assisted  in  various  ways,  as  follows: 

I.  Through  active  exercise,  which  produces  more  complete 
24 


336 


FOOD   DIGESTION. 


oxidation  and  the  formation  of  a  larger  proportion  of  water  and 
carbon  dioxide. 

2,  By  diuretics,  large  draughts  of  saline  waters,  and  occasional 
doses  of  saline  cathartics. 

3.  By  Turkish  baths,  which  increase  the  elimination  from  the 
skin. 

The  data  given  below,  which  are  derived  from  Bauer,  exhibit  the 
balance  of  income  of  food  and  output  of  waste  of  the  body  under 
different  conditions  of  rest  and  activity. 


Income  of  Food  and  Output  of  Waste  (Bauer). 


Small,  ill-nour- 

Rest and 

Work  and 

ished  man ; 

abundant  diet. 

abundant  diet. 

rest  and 
abundant  diet. 

Grammes. 

Grammes. 

Gramtnes. 

139-7 

I5I-3 

I5I-I 

41-5 

48.1 

61.8 

450.0 

450.0 

450.0 

500.0 

500.0 

509.6 

1,025.0 

1,065.9 

1,012.7 

70.0 

60.2 

58.8 

30.0 

30.0 

30.0 

70.0 

70.0 

70.0 

17.0 

17.0 

17.0 

4.2 

4.9 

4-3 

286.3 

489.1 

41.4 

709.0 

1,006.1 

600.7 

3,342.7 

3,892.6 

3,007.4 

1.343- 1 

1,261.1 

1,069.6 

II4-5 

129.0 

137-1 

1,739-7 

2,545-5 

1,597-8 

3,197-3 

3-935-6 

2,804.5 

+  145-4 

-43 -o 

-1-  202 . 9 

Income. 

Meat 

White  of  egg 

Bread 

Milk 

Beer 

Suet 

Butter 

Starch  

Sugar 

Salt 

Water 

Oxygen  from  air 

Total 

Output, 

Urine 

Faeces 

Breath 

Total 

Balance 


THE    URINE    AND    FOOD. 

The  relation  of  the  composition  of  the  urine  to  the  quality  and 
quantity  of  the  food  is  highly  important. 

Independently  of  renal  disease  and  of  excessive  perspiration,  the 
occurrence  of  a  scanty  urine  means  that  too  little  fluid  is  being  in- 
gested, and  that  the  nitrogenous  waste  is  accumulating  faster  than 
it  is  being  removed. 

The  urine  secretion  is  normally  increased  in  quantity  after  meals, 
and  is  diminished  during  fasting  and  in  sleep.  The  increased  rate 
of  secretion  lasts  for  two  or  three  hours,  and  then  lessens.  The  in- 
crease usually  begins  within  an  hour  after  breakfast,  but  not  for  two 
or  three  hours  after  dinner.     This  may  be  owing  to  the  slower  ab- 


FOOD  EQUIVALENTS.  337 

sorption  of  fluid  which  occurs  with  the  heavier  meal — i.  e.,  while 
solid  food  is  retained  in  the  alimentary  canal,  it  holds  back  the  fluid 
like  a  sponge.  The  maximum  rate  of  secretion  is  also  reached 
somewhat  later  after  dinner,  sometimes  not  for  four  hours. 

After  mi.ved  meals  the  quantity  of  urea  is  more  than  doubled, 
and  the  phosphates  and  urates  are  increased  in  nearly  the  same 
ratio.  Proteid  foods  always  increase  the  output  of  urea,  urates,  or 
uric  acid,  while  vegetable  foods  increase  the  phosphates  and  sul- 
phates. 

Klemperer  has  stated  that  in  diseases  characterised  by  nitrog- 
enous tissue  waste  the  latter  is  reduced  by  giving  carbohydrates. 
In  other  words,  the  carbohydrates  save  the  consumption  of  tissue 
and  consequent  production  of  urates  or  urea. 

Meat  and  albuminous  foods  in  general  tend  to  make  the  urine 
more  acid,  whereas  milk  and  vegetables  make  it  more  alkaline. 

TOBACCO   AND    FOOD. 

The  use  of  tobacco  in  its  relation  to  digestion  is  a  subject  very 
closely  allied  to  dietetics,  but  a  brief  mention  of  it  only  can  be  made 
here.  Like  alcohol,  undoubtedly  most  persons  are  better  without 
it,  and  its  abuse  is  well  known  to  disorder  digestion  through  the 
action  of  nicotine  upon  the  circulation,  and  especially  upon  the 
vagus  nerve.  No  definite  rules  can  be  formulated  for  the  use  of 
tobacco  in  relation  to  meals  beyond  those  suggested  by  the  fact 
that  the  action  of  tobacco  is  always  less  likely  to  prove  irritating  if 
it  is  smoked  while  there  is  abundant  food  in  the  stomach.  The 
after-dinner  cigar  in  many  persons  promotes  the  secretion  of  gastric 
juice,  and  there  are  those  in  whom  a  mild  cigar  after  breakfast 
favours  peristalsis  and  the  evacuation  of  the  bowels.  If  there  is 
any  tendency  to  indigestion  of  starchy  or  saccharine  foods,  it  is 
usually  aggravated  by  the  use  of  tobacco  in  any  form. 

As  observed  elsewhere,  when  food  cannot  be  obtained  after 
fatiguing  exercise  or  a  forced  march,  the  moderate  use  of  tobacco  is 
often  found  to  temporarily  replace  it,  at  least  to  the  extent  of  lessen- 
ing the  feeling  of  weariness  (see  Substitutes  for  Food,  page  260). 
Smoking  immediately  before  meals  may  destroy  the  appetite  and 
interfere  with  the  digestion  of  the  food. 

FOOD   EQUIVALENTS. 

It  is  easy  to  compute  the  chemical  equivalents  of  foods  as 
analysed  outside  of  the  body.  It  is  quite  another  matter  to  com- 
pute them  with  accuracy  within  the  body.  Most  writers  upon  die- 
tetics, however,  make  some  attempt  to  do  this,  and  the  following 


338 


FOOD   DIGESTION. 


data  may  be  accepted  as  approximately  correct :  One  pound  of  lean 
beef  equals  in  nutrient  value  three  eggs  or  two  pints  of  milk.  One 
pound  of  wheat  equals  3.5  pounds  of  potatoes. 

Of  common  cheese,  Parkes  estimated  that  "  about  half  a  pound 
contains  as  much  nitrogenous  substance  as  one  pound  of  meat,  and 
one  third  of  a  pound  as  much  fat." 

Van  Noorden  estimates  that  as  a  fat  former  seven  grammes  of 
fat  equal  9.3  grammes  of  alcohol. 

Oertel  says  that  "  one  part  of  fat  is  iso-dynamic  with  2.4  parts  of 
carbohydrates,  on  an  average,"  and  one  part  of  fat  develops  as  much 
heat  and  force  as  2. 11  parts  of  albumin  (Voit). 

Church  gives  the  following  table  of  the  estimated  equivalents  of 
foods  which  would  yield  the  necessary  daily  supply  of  nitrogen  if 
eaten  alone  : 


Pounds. 

Ounces. 

Oatmeal 

I 
2 
2 

3 
24 

54 
6 

3 

10 

Eecs 

Lean  beef 

I 

Wheat  bread 

13 

Potatoes 

White  turnips 

4 

8 

Cow's  milk 

Rice 

7 

To  obtain  the  necessary  daily  supply  of  carbon 


Bacon 

Cow's  milk . . 
Wheat  bread 

Eggs 

Rice 

Turnips 

Lean  beef. . . 
Potatoes . . . . 


PART   VI. 

THE  GENERAL  RELATIONS  OF  FOOD  TO  SPECIAL 
DISEASES.— DISEASES  WHICH  ARE  CAUSED  BY 
DIETETIC  ERRORS. 


i 


THE    GENERAL    RELATIONS    OF    FOOD    TO    SPECIAL 

DISEASES. 

There  are  two  methods  of  adapting  diet  for  the  sick  :  First,  by- 
giving  one  half,  one  third,  or  one  fourth  of  the  ordinary  quantity  of 
food  for  health;  second,  by  altering  the  quality  of  the  different 
classes  of  foods,  and  reducing  the  total  amount  simultaneously  or 
not,  as  required.  The  former  method  is  simpler  and  less  trouble- 
some, and  for  some  few  cases  it  may  prove  sufficient.  It  is  to  be 
regretted  that  it  is  a  routine  method  adopted  in  many  hospitals,  for 
it  is  unscientific,  besides  being  often  wasteful  and  radically  wrong. 
The  second  method  presupposes  a  knowledge  of  the  relations 
of  diet  to  disease,  and  requires  careful  supervision.  In  speaking  of 
this  subject  Parkes  wrote  :  "  It  is  certain  that  the  physician  can  in 
this  way  wield  a  great  power,  which,  if  less  striking  than  that  ob- 
tained more  rapidly  by  drugs,  is  yet  of  immense  moment." 

The  same  aliments  which  in  health  produce  definite  results  in 
furnishing  energy  and  repairing  tissue  loss  may  fail  completely  in 
disease.  Such  is  the  case  in  diabetes  when  starches  become  not  only 
a  useless  but  a  harmful  food,  and  in  severe  albuminuria,  when  meats 
only  aggravate  the  albuminuric  waste. 

In  the  majority  of  severe  diseases,  and  especially  of  acute  and 
febrile  diseases,  the  proteids  and  fats,  aside  from  those  of  milk,  be- 
come less  assimilable  than  the  carbohydrates.  Beneke  attributes 
this  to  the  fact  that  carbohydrates  are  respiratory  foods — i.  e.,  their 
consumption  results  in  the  production  of  carbon-dioxide  gas  and 
water,  and  the  elimination  of  carbon  dioxide  proceeds  in  disease 
very  much  as  in  health.  If  carbohydrates  are  not  therefore  fur- 
nished, inanition  ensues,  for  the  tissues  begin  to  consume  their  own 
substance. 

There  are,  on  the  other  hand,  some  few  diseases,  such  as  tubercu- 

839 


340 


GENERAL    RELATIONS   OF   FOOD    TO    SPECIAL   DISEASES. 


losis,  the  scrofulous  diathesis,  or  anaemia,  in  which  proteids  and  fats 
may  be  distinctly  required,  and  others  again  may  temporarily  de- 
mand a  purely  nitrogenous  diet. 

Food  improper  in  quality  or  deficient  in  quantity  is  sure  to  be 
not  only  a  direct  source  of  disease,  but  indirectly,  by  lowering  the 
vitality  of  the  body,  it  leaves  it  an  easy  prey  to  epidemic  and  con- 
tagious diseases  of  every  sort.  This  was  strikingly  shown  during 
the  ravages  of  the  plague  in  the  Middle  Ages,  and  it  has  been  ap- 
parent in  the  history  of  all  recent  famines.  (See  Starvation,  page  274, 
and  Famine,  page  281.) 

The  important  relation  of  food  to  disease  in  regard  to  its  quantity 
and  composition,  as  well  as  the  frequency  and  method  of  its  admin- 
istration, are  becoming  more  and  more  thoroughly  appreciated. 
This  is  owing  in  great  part  to  improved  methods  of  diagnosis  and 
to  modern  means  of  clinically  discriminating  between  different  kinds 
of  gastric  and  intestinal  indigestion.  It  is  also  due  to  an  increasing 
knowledge  of  the  chemistry  of  food,  of  food  preparation  by  cooking, 
and  of  "artificial  digestion." 

There  is  still  much  difference  of  opinion  in  regard  to  the  best 
dietaries  for  certain  diseases,  such,  for  example,  as  gout  and  obesity, 
but  the  general  principles  of  dietetics  are  to-day  well  established  and 
more  widely  understood  and  practised  than  ever  before,  and  starva- 
tion in  fevers,  like  excessive  venesection  and  similar  depleting  meas- 
ures, is  no  longer  carried  to  the  former  injurious  extreme.  There 
remains  much  to  be  learned  in  regard  to  dietetics ;  and  the  great 
variations  in  digestive  power  which  are  encountered  in  individual 
cases  of  disease  and  in  personal  idiosyncrasy,  together  with  the  in- 
creasing varieties  of  foods  and  food  preparations,  make  the  rela- 
tion of  diet  to  disease  a  constantly  broadening  subject,  the  impor- 
tance of  which  cannot  be  overrated.  It  is  to  be  regretted  that  the 
study  of  dietetics  is  not  more  thoroughly  taught  as  a  necessary 
part  of  medical  education,  and  that  thorough  systematic  instruction 
in  this  practical  branch  of  science  is  omitted  from  the  curriculum  of 
our  medical  schools.  For  many  physicians  it  seems  far  easier  to 
write  a  brief  prescription  for  a  "  nerve  tonic  "  or  cathartic  pill  than 
to  take  the  time  and  pains  to  state  in  writing  for  their  patients  a 
definite  dietary  which  in  very  many  cases  will  prove  an  invaluable 
adjunct  to  medicinal  treatment,  if  not  in  itself  a  curative  measure. 
Sometimes  indeed  they  appear  possessed  with  the  idea  that  the 
minutiae  of  dietetics  are  beneath  consideration,  whereas  in  reality, 
like  the  details  of  good  nursing,  they  are  most  important,  and  a  care- 
ful attention  to  them  and  a  close  interrogation  into  the  ordinary 
habits  of  the  patient  in  regard  to  his  daily  regimen  is  sure  of  appre- 
ciation and  of  beneficial  results. 

In  all  acute  febrile  diseases  and  in  all  so-called  "wasting  "  dis- 


DISEASES   CAUSED   BY   DIETETIC   ERRORS. 


341 


eases  in  which  there  is  faulty  assimilation  of  the  food,  the  digestive 
functions  are  impaired,  while  the  rapid  tissue  waste  increases  the 
need  for  nutriment  to  replace  it.  In  such  cases  enfeebled  digestive 
powers  must  be  taken  into  account,  and  while  endeavouring  to  sup- 
ply the  increased  demand  for  food,  every  effort  should  be  made  to 
relieve  the  alimentary  canal  of  unnecessary  labour  by  supplying 
those  preparations  which  will  yield  the  necessary  amount  of  nutri- 
tion and  force  with  a  minimum  expenditure  of  energy.  Moreover, 
the  conditions  of  elimination  of  waste  materials  from  the  tissues 
must  be  studied  in  relation  to  the  composition  of  different  foods  in 
order  to  prevent  the  overworking  of  the  excretory  organs. 

It  may  be  asserted  that  there  is  almost  no  disease  of  long  dura- 
tion and  severity,  and  certainly  no  disease  accompanied  by  grave 
constitutional  disturbances,  the  course  of  which  cannot  in  a  measure 
be  controlled  or  benefited  by  thorough  study  of  the  nature  and  uses 
of  foods.  There  are  many  acute  aliments  in  which  undoubted  bene- 
fit is  derived  from  greatly  diminishing  or  altogether  withholding 
temporarily  the  consumption  of  food,  while  there  are  others  in  which 
forced  feeding — that  is,  increasing  the  quantity  of  food  to  the  utmost 
capacity  of  the  digestive  organs — is  a  necessity. 

The  general  relations  of  food  to  the  organism,  as  well  as  the  na- 
ture of  foods  and  the  processes  involved  in  their  digestion,  absorp- 
tion, and  assimilation,  have  received  full  consideration  in  the  preced- 
ing pages.  In  the  following  chapters  the  principles  briefly  outlined 
above  will  be  considered  in  their  application  to  individual  diseases. 
At  the  risk  of  some  repetition,  it  has  been  thought  best  to  make 
the  dietetic  treatment  of  each  disease  as  comprehensive  as  possible 
under  the  different  headings  considered,  and  to  emphasise  its  value 
by  a  brief  synopsis  of  the  more  important  symptoms  which  arise,  and 
a  discussion  of  the  indications  to  be  met  by  appropriate  dieting. 


DISEASES  CAUSED  BY  DIETETIC  ERRORS. 

While  the  course  of  the  majority  of  all  diseases  is  obviously  influ- 
enced by  the  quantity  and  quality  of  the  food  eaten,  there  are  par- 
ticular diseases  which  are  directly  caused  by  improper  diet.  This 
causative  relation  concerns: 

I.  Insufficient  food.  II.  Overeating  and  overdrinking.  III.  Food 
in  itself  wholesome,  but  which  is  injurious  because  the  ingredients 
are  not  properly  balanced.  IV.  Food  containing  parasites  or  their 
embryos.  V.  Food  containing  ptomaines.  VI.  Food  containing 
other  poisons,  grain  poisoning,  etc.  VII.  Food  conuining  adulter- 
ants. VIII.  Food  containing  micro-organisms.  IX.  Food  which  is 
in  itself  wholesome,  but  against  which  personal  idiosyncrasy  exists. 
X.  Alcohol  as  a  food  and  poison. 


342 


DISEASES  CAUSED   BY  DIETETIC  ERRORS. 


I.  Insufficient  Food. 


The  general  effects  of  starvation  have  been  described  in  the  study 
of  the  proper  quantity  of  food  (page  274).  The  effects  of  the  depriva-^ 
tion  of  water  are  discussed  on  page  35.  Insufficient  food  may  cause 
the  condition  of  marasmus,  and  is  an  important  agent  in  producing 
some  forms  of  anaemia  (see  Marasmus). 

II.  Overeating  and  Overdrinking. 

Both  overeating  and  overdrinking  may  be  (i)  temporary — that  is, 
the  result  of  an  occasional  debauch;  or  (2)  chronic. 

1.  Temporary  overeating  may  apply  to  the  excessive  consump- 
tion (a)  of  a  mixed  diet,  or  (d)  of  particular  articles  of  food.  The 
former  (a)  causes  dyspepsia,  or,  in  extreme  cases,  acute  gastro-enter- 
itis.  The  latter  (d)  may  also  cause  dyspepsia  and  diarrhoea,  or  such 
affections  may  be  produced  as  glycosuria,  from  excessive  indulgence 
in  candy  and  sweets ;  acne  and  other  skin  diseases,  from  the  too  lib- 
eral consumption  of  fats. 

Temporary  overeating  at  one  or  two  meals  may  not  produce  any 
serious  effect,  but  if  the  excess  in  feeding  be  long  continued  a  variety 
of  ills  result,  attributable  directly  to  overloading  of  the  alimentary 
canal  and  to  the  accumulation  of  waste  matter  in  the  tissues,  and 
consequent  imperfect  oxidation  processes. 

The  excess  of  food  may  be  injurious  in  one  of  two  ways : 

First,  if  it  is  not  absorbed,  it  ferments  abnormally  in  the  alimen- 
tary canal.  There  is  a  limit  to  the  quantity  of  every  food  which  can 
be  digested  in  a  given  time ;  beyond  this  the  food,  whether  starches, 
fats,  sugars,  or  proteids,  may  decompose,  or  pass  away  unaltered. 

Second,  if  the  excess  be  absorbed  the  blood  is  overwhelmed,  and 
the  excretory  organs  are  overworked. 

The  most  northern  Eskimos  and  Yakuts  often  eat  but  one  meal  a 
day,  and,  owing  to  the  uncertainty  of  their  supplies,  they  occasionally 
have  to  make  the  interval  longer.  As  a  result,  when  they  do  find 
food  in  abundance,  they  gorge  themselves,  and  they  are  noted  for  the 
relatively  large  size  of  their  abdomens  and  stomachs — which  is,  how- 
ever, the  only  inconvenience  which  they  seem  to  suffer  from  such 
irregular  habits  (see  Gluttony,  page  261). 

2.  Chronic  overeating  may  cause  such  diseases  or  diatheses 
as  obesity,  gout,  lithaemia,  oxaluria,  and  the  formation  of  renal,  vesi- 
cal, and  hepatic  calculi.  It  is  very  certain  to  cause  congestion  of 
the  liver  and  the  condition  known  as  "  biliousness,"  in  which  the 
stomach  and  intestines  are  engorged,  constipation  results,  the  tongue 
is  heavily  coated,  the  bodily  secretions  are  altered  in  composition, 
the  urine  especially  becoming  overloaded  with  salts,  the  liver  be- 
comes congested,  and  finally  the  nervous  and  muscular  systems  are 


OVEREATING   AND   OVERDRINKING. 


343 


affected,  with  the  result  of  the  production  of  headache  and  feelings 
of  fatigue,  lassitude,  drowsiness,  and  mental  stupor. 

For  persons  leading  sedentary  lives,  excessive  consumption  of 
animal  food  is  more  injurious  than  vegetable  food,  for  the  reasons 
given  above,  although  obesity  is  more  favoured  by  excess  in  vegetable 
diet  and  sweets.  The  nitrogenous  foods,  requiring,  as  they  do,  a 
large  consumption  of  oxygen  for  their  complete  combustion  and 
reduction  to  urea  and  allied  products,  produce  forms  of  waste  mat- 
ter in  the  system  which  are  more  deleterious  than  the  carbohydrates 
that  are  converted  into  water  and  carbonic  acid,  and  are  more  easily 
eliminated.  It  is  for  this  reason  that  defective  nitrogenous  metab- 
olism alters  the  composition  of  the  blood  and  paves  the  way  for 
disorders  of  nutrition,  such  as  lithiasis. 

Patients  suffering  from  severe  epilepsy  and  from  certain  forms 
of  insanity,  chiefly  manias,  and  sometimes  hypochondriacs,  at  times 
gorge  themselves  with  food  and  drink. 

The  presence  of  intestinal  roundworms  and  tapeworms  may  give 
rise  to  overeating,  though  this  by  no  means  always  follows. 

Overeating  is  apt  to  be  carried  to  an  injurious  extent  by  the 
half-starved  poor  if  they  have  sudden  access  to  plenty,  and  by 
convalescents  from  typhoid  fever. 

Bulimia  is  a  form  of  perverted  sensation,  causing  inordinate 
craving  for  food  (see  page  304). 

Overeating  not  only  taxes  the  digestivesystem,  but,  what  is  often 
more  serious,  it  throws  too  great  a  strain  upon  the  glandular  and 
excretory  organs,  especially  the  liver  and  kidneys,  and  if  the  habit 
is  long  continued,  disease  of  the  nature  above  described  inevitably 
results.  In  like  manner  the  overfed  boiler  becomes  sooner  burned 
out,  and  its  fires  choked  with  ashes  which  accumulate  faster  than 
they  can  be  removed.  Overeating,  especially  among  the  well-to-do, 
is  the  commonest  dietetic  error,  and  looking  at  the  question  in  its 
broadest  aspects,  it  is  quite  certain  that  the  foundation  for  more 
disease  is  laid  by  this  habit  than  by  overdrinking  (see  Alcohol, 
page  206).  The  former,  indeed,  sometimes  conduces  to  the  latter, 
and  there  are  some  examples  of  alcoholism  in  which  the  desire  for 
drink  is  only  aroused  and  fostered  by  previous  excesses  in  eating. 

Overdrinking,  except  of  alcohol  (which  is  considered  under 
the  heading  of  Alcoholism,  page  364),  is  not  common,  and  is  mainly 
confined  to  the  excessive  consumption  of  tea  and  coffee,  which  re- 
sults in  insomnia,  cardiac  palpitations,  and  various  neuroses.  Dila- 
tation of  the  stomach  has  been  attributed  in  some  cases  to  over- 
indulgence in  mineral  waters,  but  such  instances  are  very  unusual. 
Polyuria  and  diabetes  insipidus  have  also  been  ascribed  to  the  ab- 
normal consumption  of  fluids,  but  without  strong  proof.  Excessive 
use  of   milk  as  a  beverage   usually   results   in  "biliousness"  and 


344  DISEASES   CAUSED   BY   DIETETIC   ERRORS. 

constipation,  but  for  the  reason  that  it  is  really  a  solid  food — that  is, 
it  becomes  such  immediately  on  entering  the  stomach.  Thirst  is 
often  extreme  in  fevers,  diabetes,  and  other  conditions,  but  the  drink- 
ing of  exceptionally  large  quantities  of  water  is  by  no  means  always 
harmful,  and  it  is  often  desirable  to  recommend  it  as  a  diluent  and 
diuretic.  The  propriety  of  restricting  its  use  in  dropsies,  gastric 
disorders,  etc.,  will  be  considered  under  the  appropriate  headings 
(see  Gastric  Catarrh,  Ascites,  Diabetes). 

III.  Food  in  itself  Wholesome,  but  which  is  Injurious 

BECAUSE   the   INGREDIENTS   ARE  NOT   PROPERLY  BALANCED. 

Such  diet  may  produce  anaemia,  from  lack  of  meat  or  other 
animal  food ;  scurvy,  from  preponderance  of  salt  meat  and  fish  and 
lack  of  fresh  fruits  and  vegetables  ;  rickets  and  scrofula,  from  errors 
in  infant  feeding,  such  as  excess  of  amylaceous  and  lack  of  animal 
food,  necessary  salts,  etc. ;  acne,  or  eczema,  from  food  too  rich  in 
fats;  constipation,  from  a  too  nutritious  and  concentrated  diet;  pos- 
sibly rheumatism,  from  various  dietetic  errors. 

The  belief  is  held  by  some  authorities  that  a  diet  of  coarse  cereals 
and  vegetables  favours  the  development  of  chronic  endarteritis  (see 
Vegetarianism,  page  28). 

IV.  Food  containing  Parasites  or  their  Embryos. 

Food  sometimes  serves  as  the  medium  for  the  introduction  of 
parasites  or  their  embryos,  such  as  the  tapeworm,  roundworm,  echi- 
nococcus,  and  trichina. 

In  many  cases  the  source  of  infection  is  found  in  the  consumption 
of  raw  or  very  imperfectly  cooked  swineflesh  and  other  meats  used 
in  the  manufacture  of  sausages  and  similar  preparations  which  are 
carelessly  handled  and  come  in  contact  with  the  viscera  of  the  ani- 
mals in  which  the  parasites  or  embryos  reside  in  some  intermediate 
stage  of  development.  Another  possible  source  of  infection,  espe- 
cially of  intestinal  worm  larvae,  is  in  the  excrement  of  animals,  which 
is  permitted  to  pollute  raw  vegetables  growing  upon  the  ground. 
Manure  is  freely  spread  about,  and  dogs  infested  with  worms,  or  a 
casual  pig  allowed  at  large  in  a  vegetable  garden,  may  contaminate 
by  their  faeces  such  vegetables  as  grow  low  upon  the  ground  and 
are  usually  eaten  raw,  as  lettuce,  celery,  cabbage  (coleslaw),  etc. 
Fortunately,  this  is  by  no  means  a  common  source  of  infection,  but 
it  is  well  to  remember  that  several  cases  have  been  definitely  traced 
to  such  a  source,  and  this  explains  the  occasional  presence  of  tape- 
worms in  people  who  never  eat  raw  meats,  ham,  or  sausage,  or  the 
flesh  of  swine  in  any  form.  No  animal  should  ever  be  allowed  to 
roam  in  a  vegetable  garden.     Other  varieties  of  parasites  or  their 


INTESTINAL   WORMS. 


345 


larvae  may  occasionally  be  introduced  with  the  food  or  water,  such, 
for  example,  as  the  Dracunculus  tnedinensis,  which  produces  the 
Guinea-worrn  disease,  or  Dracontiasis,  the  larvae  of  which  are  some- 
times swallowed  in  drinking  water  by  the  natives  of  parts  of  Africa 
and  the  East  Indies. 

INTESTINAL   WORMS. 

The  presence  of  intestinal  worms,  such  as  the  roundworm, 
Ascaris  lumbricoides,  and  various  species  of  cestodes  or  tapeworms, 
requires  no  special  dietetic  care  beyond  the  preventive  treatment  of 
avoiding  raw  or  imperfectly  cooked  flesh  and  submitting  to  a  period 
of  starvation  for  twenty-four  hours,  in  order  that  the  intestine  may 
be  completely  emptied  of  food  before  an  anthelmintic  is  given,  so 
that  it  may  more  certainly  reach  the  worms. 

There  are  two  principal  varieties  of  tapeworm  in  man,  besides 
four  or  five  others,  which  are  very  rarely  present  in  the  intestine, 
being  derived  from  the  lower  animals  through  habits  of  filth  or 
carelessness  in  preparing  food. 

Of  these  two  varieties,  the  commonest  in  this  country  is  the  beef 
tapeworm,  Tcenta  saginata,  or  mediocanellata ;  the  other,  the  pork 
tapeworm,  or  Tcenia  solium,  is  more  often  found  in  Europe  and 
Asia. 

The  Tcenta  mediocanellata  is  a  segmented  worm,  having  a  large 
square  head  presenting  four  suckers,  by  which  it  maintains  its  hold 
upon  the  intestinal  mucosa  without  the  aid  of  booklets.  The  seg- 
ments increase  very  slowly  in  size  behind  the  head,  and  finally  attain 
a  breadth  of  eight  to  ten  millimetres  and  a  length  of  seventeen  to 
eighteen  millimetres,  while  the  whole  animal  may  reach  a  length  of 
twenty  feet,  or  even  become  longer  than  the  intestine.  Fragments 
of  the  worm  are  constantly  breaking  off,  compressed  bythe  waste 
matter  of  the  food,  and  with  it  are  swept  out  of  the  gut. 

The  Tcenia  solium  is  not  so  long  as  the  mediocanellata,  measuring 
usually  from  six  to  twelve  feet.  The  head,  which  is  quite  small, 
presents  four  suckers  and  several  minute  hooks,  which  enable  the 
animal  to  secure  a  firm  hold  upon  the  mucous  membrane.  Behind 
the  head  are  the  series  of  segments,  many  hundred  in  number,  con- 
stituting the  body.  They  gradually  increase  in  size,  and  the  larger 
ones  contain  male  and  female  organs  of  generation,  each  segment 
being  supplied  with  both  varieties.  The  larger  segments  attain  a 
'size  of  seven  to  eight  millimetres  by  ten  millimetres.  Each  mature 
segment  contains  an  enormous  number  of  ova — often  several  thou- 
sand—and in  about  three  months,  when  the  worm  has  reached  its 
full  size,  the  segments,  which  are  narrower  and  smaller  than  those  of 
mediocanellata,  are  continually  breaking  off  and  passing  out  with 
the  faeces.     Pigs  eat  the  ova,  and  digest  them.     The  ova  consist  of 


346 


DISEASES   CAUSED   BY   DIETETIC   ERRORS. 


shells  which  contain  minute  embryos  with  six  hooklets.  The  em- 
bryos make  their  way  into  the  viscera  or  muscles  of  the  animal, 
where  they  lodge  and  develop  to  form  the  larvae  or  cysticerci,  called 
also  **  measles."  If  the  measled  hog  meat  is  eaten  by  man,  and 
imperfectly  cooked,  the  cysticerci  develop  with  the  intestinal  worms 
above  described. 

The  worms  infest  man  at  all  ages,  from  early  childhood  up. 
They  may  cause  no  symptoms,  but  sometimes  give  rise  to  a  raven- 
ous appetite,  as  they  interfere  with  intestinal  digestion  and  absorp- 
tion. They  occasionally  excite  reflex  nervous  disturbances.  Their 
presence  is  easily  made  certain  by  the  finding  of  either  the  ova  or 
the  complete  segments  in  various  lengths  in  the  stools. 

Treatment. — The  patient  should  be  put  upon  very  short  rations 
for  two  days,  during  which  time  the  bowels  must  be  well  emptied. 
The  evening  before  giving  the  vermifuge  the  patient  should  take  a 
light  supper  of  bread  and  milk  or  a  sandwich,  and  that  night  a  brisk 
cathartic.  It  is  best  to  give  the  medicine  the  next  morning  fasting. 
By  this  means  the  intestines  become  almost  empty,  and  the  head  of 
the  worm  is  left  unprotected,  so  that  whatever  remedy  is  used  to 
kill  it  will  make  it  loosen  its  hold.  Another  laxative  may  be  given 
a  few  hours  later,  and  if  the  patient  eats  bulky  food,  such  as  bread 
and  potatoes,  for  a  day  or  two,  and  keeps  the  bowels  active,  the 
worm  may  be  completely  dislodged  and  crowded  out.  The  stools 
must  be  floated  in  water  and  closely  examined  for  the  head,  for  if 
this  is  not  obtained  the  worm  is  sure  to  grow  again  in  three  or  four 
months.  There  are  many  tseniacides.  One  of  the  least  disagree- 
able and  most  efficient  when  properly  administered  is  pumpkin  seed. 
The  seeds  should  be  husked,  and  three  ounces  may  be  pounded  in  a 
mortar,  macerated,  mixed  with  honey  into  a  paste,  and  eaten  spread 
like  jam  upon  a  thin  slice  of  bread. 

TRICHINIASIS. 

iEtiology. — Trichiniasis  is  a  parasitic  disease  produced  by  the 
embryos  of  a  worm,  the  Trichina  spiralis,  which  work  their  way  into 
the  voluntary  muscles  and  there  become  embedded.  Among  the 
parasites  liable  to  be  eaten  with  raw  meats  this  one  is  by  far  the 
worst  and  most  fatal  in  its  effects.  The  habitat  of  the  adult  worm 
is  the  small  intestine.  During  the  emigration  of  the  embryos  into 
the  voluntary  muscles  a'  group  of  characteristic  symptoms  is  pro-^ 
duced.  The  parasites  have  the  following  appearance:  The  adult 
male  measures  1.5  millimetre  in  length  ;  the  female  is  from  two  to 
two  and  a  half  times  as  long.  The  embryo  is  0.6  to  i.o  millimetre 
in  length,  and  when  at  rest,  encapsulated  in  the  muscle,  is  coiled  in 
a  spiral.  It  has  a  blunt  tail  and  a  sharp  head.  The  adult  male  has 
two  small  projections  from  the  caudal  end.     The  ovoid  capsule  first 


TRICHINIASIS.  347 

appears  translucent,  but  later,  from  the  deposition  of  salts  of  lime, 
it  becomes  opaque. 

Infection  in  man  is  caused  by  the  eating  of  ham  and  pork  from 
hogs  whose  bodies  contain  the  parasite.  Among  these  animals  it  is 
of  quite  frequent  occurrence.  It  is  also  spread  through  the  agency 
of  rats,  which  are  eaten  by  hogs  (Dock).  Salmon  reports  that  in 
American  hogs  the  ratio  affected  is  slightly  over  2  per  cent,  but  this 
is  doubtless  far  too  high  an  estimate.  In  Germany  the  proportion 
is  I  in  1,852. 

Natural  History  of  the  Parasite. — After  eating  flesh  which 
contains  the  embryos  the  process  of  digestion  dissolves  their  cap- 
sules, and  they  are  liberated,  passing  into  the  small  intestine,  where, 
with  the  presence  of  the  favourable  conditions  of  warmth,  moisture, 
and  food,  they  reach  their  adult  growth  in  from  three  to  six  days. 
Rapid  reproduction  takes  place  in  the  intestine,  and  the  number 
of  young  produced  by  a  single  female  worm  varies  up  to  at  least  a 
thousand.  In  a  week  or  more  after  the  ingestion  of  the  parasites 
the  newly  developed  embryos  pass  out  through  the  intestinal  wall 
and  mesentery,  seeking  the  muscles  which  they  enter ;  they  then 
work  their  way  through  the  connective  tissue  between  the  fasciculi 
or  the  separate  muscle  fibres,  and  finally  enter  the  latter,  where  a 
fortnight's  further  development  produces  the  complete  muscle  form. 

Recent  observations  of  Askanazy  point  to  the  conclusion  that 
the  adult  female  deposits  the  embryos  within  the  walls  of  the  in- 
testinal villi,  not  setting  them  free  in  the  intestine,  as  heretofore 
supposed.  From  the  villi  they  penetrate  the  muscles,  as  above 
mentioned. 

Thornbury  recently  reported  at  the  Buffalo  Academy  of  Medicine 
the  results  of  analysis  of  500  cases  of  infected  swine.  In  these  ani- 
mals the  parasite  was  found  in  the  diaphragm  400  times,  in  the  loin 
290  times,  and  in  the  neck  170  times.  "The  point  of  predilection 
therefore  appears  to  be  the  diaphragm.  This  is  explained  by  its 
close  proximity  to  the  digestive  tract,  from  which  the  trichinae  pri- 
marily bore."  In  three  cases  in  man  which  he  examined  the  trichinae 
were  found  principally  in  the  extremities,  "one  microscope  slide 
from  the  biceps  of  an  arm  containing  fifty  of  the  parasites."  They 
were  also  present  in  the  diaphragm,  intercostal  and  abdominal 
muscles. 

The  embryos,  when  lodged  in  the  muscle  fibres,  act  as  foreign 
bodies  or  irritants  and  excite  an  interstitial  myositis  with  the  forma- 
tion of  a  capsule  around  each  embryo.  But  one  embryo  may  be 
lodged  in  a  single  capsule.  Once  within  the  muscle  fibres,  embryos 
remain  without  change  until  the  capsule,  the  completion  of  which 
requires  about  six  weeks,  is  in  some  way  destroyed.  After  forma- 
tion of  the  capsule  a  precipitation  of  lime  salts  occurs  slowly  within 


348 


DISEASES   CAUSED    BY   DIETETIC    ERRORS. 


it  for  four  or  five  months.  The  embryos,  thus  securely  protected  in 
a  strong  envelope,  may  retain  their  vitality  for  many  years,  and  it  is 
claimed  that  they  have  survived  for  at  least  two  decades,  but  the 
worms  themselves  not  infrequently  become  calcified.  Other  animals 
besides  hogs  may  harbour  this  parasite,  among  which  are  the  rat,  cat, 
mouse,  and  fox,  and  it  can  be  artificially  inoculated. 

Prophylaxis. — The  prevention  of  trichiniasis  should  consist  in 
the  more  careful  feeding  of  swine  upon  grain  instead  of  offal,  and 
for  man  the  only  absolute  prevention  is  the  extremely  thorough 
cooking  of  all  swine  flesh,  for  a  temperature  of  140°  F.  is  fatal  to 
the  embryos.     Smoking  and  pickling  is  also  preventive. 

"  In  the  usual  curing  solutions  trichinae  are  killed  within  six 
weeks  in  thin  pieces  of  meat,  but  in  thick  pieces  they  can  exist  as 
long  as  four  months"  (Dock). 

The  presence  of  the  parasites  in  countless  numbers  in  the  flesh 
of  the  hog  may  give  rise  to  no  symptoms  of  any  kind  in  the  animal, 
and  it  is  this  fact  which  makes  the  eating  of  raw  ham,  pork,  and 
sausages  particularly  dangerous  unless  the  meat  of  the  animals  killed 
has  been  subjected  to  a  searching  microscopic  examination.  It  is 
the  safest  rule  never  to  eat  such  meats.  The  difficulty  of  detecting 
the  parasite  in  the  hog  is  considerably  increased  by  the  fact  that  the 
calcification  is  very  much  slower  than  it  is  in  man,  so  that  the  worms 
are  more  readily  overlooked.  The  parasites  fortunately  are  com- 
pletely killed  by  boiling  for  some  time  the  meat  which  contains 
them,  but  pickling  or  corning  meat  or  smoking  ham  and  bacon  are 
not  necessarily  fatal  to  them. 

Frequency. — Cases  of  trichiniasis  are  occasionally  reported  in 
this  country  chiefly  among  the  Germans,  whose  fondness  for  raw 
ham  and  a  variety  of  sausages  is  well  known.  Osier  reports  the 
finding  of  456  cases,  including  122  deaths  recorded  in  America. 
Many  persons  are  often  simultaneously  affected  from  eating  the 
meat  of  the  same  animal,  thus  giving  the  disease  the  false  character 
of  an  epidemic. 

Symptoms. — The  symptoms  vary  with  the  number  of  parasites 
which  have  been  eaten.  If  very  few  are  ingested,  the  embryos  are 
not  reproduced  in  sufficient  number  to  give  rise  to  any  symptoms. 
Usually,  however,  they  are  well  marked,  and  embrace  a  stage  of 
gastro-intestinal  irritation  followed  by  systemic  infection.  The  pa- 
tient, three  or  four  days  after  eating  raw  pork  or  ham,  suffers  from 
more  or  less  severe  abdominal  cramps,  with  anorexia,  vomiting,  and 
diarrhoea.  The  latter  occasionally  becomes  severe.  General  mus- 
cular prostration  is  also  present,  and  there  may  be  chills.  In  a 
number  of  cases  the  gastro-intestinal  symptoms  may  not  be  severe 
enough  to  attract  attention,  and  the  first  symptoms  are  those  of  gen- 
eral infection,  which  develop  at  the  commencement  of  the  second 


TRICHINIASIS. 


349 


week.  There  is  an  increase  of  temperature,  amounting  to  103°  or 
104°  F,,  of  an  intermittent  or  remittent  character.  As  soon  as  the 
embryos  have  extensively  penetrated  the  muscles  they  give  rise  to 
great  local  pain  and  tenderness,  accompanied  by  swelling  and  tension 
of  all  the  muscles  affected.  The  patient  naturally  assumes  the  posi- 
tion in  which  there  will  be  the  least  strain  upon  the  muscles. 

These  symptoms  increase  in  intensity,  and  general  oedema  is  apt 
to  follow,  which  may  appear  first  in  the  face  (Osier).  When  certain 
muscles  are  implicated  more  serious  symptoms  may  result.  If  the 
diaphragm  is  invaded  or  other  muscles  of  respiration,  there  may  be 
extreme  or  even  fatal  dyspnoea.  If  the  parasites  reach  the  muscles 
of  the  face,  jaw,  and  pharynx,  mastication  and  deglutition  become 
difficult  or  impossible.  There  is  more  or  less  itching  and  burning  of 
the  skin  and  perspiration.  Urticaria  has  been  observed ;  anaemia 
and  a  marasmic  condition  eventually  develop  in  a  majority  of  cases. 
There  is  comparatively  little  disturbance  of  the  nervous  system,  and 
patients  are  usually  conscious  until  the  time  of  death,  but  in  some 
instances  a  typhoid  state  supervenes  with  delirium.  The  other  symp- 
toms which  have  been  reported  as  occasionally  present  are  loss 
of  tendon  reflex,  bronchitis,  pneumonia,  pleurisy,  albuminuria,  and 
polyuria. 

Prognosis. — Mild  cases  may  recover  within  a  fortnight.  In 
severe  cases  in  which  there  has  been  great  prostration  and  emacia- 
tion convalescence  is  retarded  for  many  weeks. 

Children  are  more  apt  to  recover  than  adults,  but  the  outlook 
depends  chiefly  upon  the  number  of  parasites  ingested.  Cases  pre- 
senting severe  diarrhoea  are  more  likely  to  recover,  probably  because 
some  of  the  parasites  are  eliminated  in  this  way. 

Mortality. — The  greatest  mortality  is  reported  between  the 
fourth  and  sixth  week.  The  causes  of  death  may  be  exhaustion 
from  choleraic  discharges,  dyspnoea,  and  inability  to  swallow.  In 
protracted  cases  inanition  results. 

Autopsies  show  that  but  few  organs  aside  from  the  muscles  are 
affected  by  anatomical  lesions.  Cohnheim  observed  fatty  degenera- 
tion of  the  liver  and  enlargement  of  the  mesenteric  glands.  The 
muscles  present  the  appearances  of  lesions  of  acute  interstitial  myo- 
sitis around  the  capsules  of  the  embryos. 

Diagnosis. — The  affection  differs  from  acute  rheumatism  in  the 
absence  of  swelling  in  the  joints  and  the  much  greater  local  tender- 
ness along  the  surface  of  the  muscles.  The  latter  are  exceedingly 
painful  both  to  pressure  and  voluntary  movement.  The  disease  m 
its  protracted  form  has  been  mistaken  for  enteric  fever,  and  un- 
doubtedly it  has  many  times  escaped  detection.  The  most  valuable 
features  in  determining  the  diagnosis  are  the  extreme  tenderness  to 
pressure  of  the  muscles,  their  swollen  condition,  and  the  general 


350 


DISEASES   CAUSED   BY   DIETETIC    ERRORS. 


oedema  and  dyspnoea.  Under  cocaine  anaesthesia  a  small  piece  of 
muscle  may  be  excised  from  the  arm  or  thigh  for  microscopic  exam- 
ination. Osier  advises  searching  the  stools  for  the  parasites,  which 
may  be  found  with  a  low-power  lens  as  glistening  threads. 

Treatment. — The  basis  of  treatment  is  to  at  once  evacuate  the 
alimentary  canal,  providing  the  fact  of  eating  the  infected  meat  is 
known  within  a  day  or  two.  Diarrhoea  should  not  be  checked.  If 
constipation  exists,  a  strong  purgative  of  calomel  and  jalap  or  castor 
oil  should  be  administered.  When  systemic  symptoms  develop,  the 
treatment  must  be  purely  symptomatic,  because  there  is  no  known 
remedy  which  will  reach  and  destroy  the  trichinae.  Every  effort 
must  be  made  to  support  the  strength  of  the  patient  until  the  em- 
bryos have  become  encysted,  after  which  the  acute  symptoms  will 
subside  of  themselves. 

V.  Food  containing  Ptomaines. 

Ptomaines  are  substances  resembling  alkaloids  which  are  formed 
in  the  alimentary  canal  by  the  decomposition  or  putrefaction  of  ni- 
trogenous foods.  They  may  also  form  in  such  food  outside  of  the 
body.  This  decomposition  is  the  result  of  the  action  of  certain 
micro-organisms  simultaneously  first  described  by  Gautier  in  France 
and  Selim  in  Bologna.  It  is  at  present  believed  that  the  constitu- 
tional symptoms  observed  in  many  infectious  diseases  are  caused  by 
similar  poisons  called  leucomaines,  which  originate  in  the  blood  and 
other  tissues  of  the  body  through  the  action  of  specific  germs.  The 
artificial  cultivation  of  micro-organisms  has  proved  that  they  are 
capable  of  forming  substances  which  have  distinct  physiological 
actions,  that  are  sometimes  highly  poisonous.  The  poisonous  pto- 
maines Brieger  calls  toxines.  Many  of  these  micro-organisms  flour- 
ish in  beef  juice,  milk,  and  various  solutions  of  nitrogenous  material ; 
and  in  the  alimentary  canal,  when  such  food  is  taken,  all  the  most 
favourable  conditions  are  present  for  the  development  of  toxines. 
When  the  proper  germs  are  ingested  for  this  purpose,  the  toxines  are 
readily  absorbed  by  the  intestinal  mucous  membrane,  and  it  is  prob- 
able that  ptomaine  poisoning  would  occur  very  much  oftener  were  it 
not  that  the  liver,  acting  as  it  does  as  a  gateway  for  the  admission 
of  nutritive  matter  for  the  body,  is  capable  of  destroying  many 
poisons  which  enter  it  from  the  intestines  through  the  branches  of 
the  portal  vein.  Corroboration  of  this  statement  is  found  in  the  fact 
that  snake  bites  of  the  surface  of  the  body  may  prove  highly  poi- 
sonous by  immediate  absorption  of  toxic  material  into  the  circu- 
lation, whereas  snake  poison  may  be  swallowed  with  impunity,  for  if 
it  is  absorbed  from  the  alimentary  canal  it  is  destroyed  in  the  liver 
before  reaching  the  nervous  system. 

The  same  is  true  of  the  action  of  putrefying  meat,  which  in  very 


POISONING   BY   MEAT   OR   GAME. 


351 


small  quantities  may  not  produce  severe  gastro-intestinal  symptoms 
or  constitutional  disturbances,  and  yet  if  inoculated  through  a  cut 
in  the  finger  may  cause  symptoms  of  a  violent  septic  character. 

Richard  (Diseases  of  Modern  Life)  reports  a  fatal  case  of  poison- 
ing from  eating  tainted  hare.  The  victim  had  had  a  small  ulcer 
beneath  the  tongue  for  some  time,  which  became  gangrenous  after 
eating  the  meat,  and  which  was  the  undoubted  source  of  inocula- 
tion. 

Ptomaines  may  be  developed  from  a  variety  of  foods,  but  the 
principal  ones  from  which  poisoning  from  time  to  time  occurs  are 
spoiled  meat,  milk,  shellfish,  and  fish. 

POISONING   BY   MEAT   OR   GAME. 

When  meat  has  been  kept  too  long  exposed  to  the  air,  or  when 
it  has  become  contaminated  in  any  manner  with  putrefactive  bac- 
teria, it  is  wholly  unfit  for  food,  yet  if  thoroughly  cooked  it  may 
not  be  necessarily  poisonous.  This  is  the  case  with  "  high  "  game. 
Dangerous  and  even  fatal  cases  of  systemic  poisoning  by  meat 
ptomaines  have  resulted  from  eating  sausages,  pork  pie,  ham,  meat 
juice,  beef,  head-cheese,  mutton,  or  veal.  The  putrefactive  change 
may  have  already  begun  in  the  meat  although  it  may  not  be  appar- 
ent by  an  altered  taste.  Sausage  poisoning  is  called  botulism  or 
allantiasis. 

It  is  a  curious  fact  that  certain  persons  have  great  toleration  for 
tainted  meats.  Among  civilised  races,  and  especially  in  England, 
the  use  of  "  high  "  game  and  mutton  is  much  less  in  vogue  at  pres- 
ent than  formerly,  but  the  Eskimos  and  many  savage  tribes  in 
Africa  eat  with  relish,  and  digest  well,  decomposing  meat  the  mere 
odour  of  which  turns  the  stomach  of  a  white  man.  Bishop  Colenso 
stated  that  among  the  Zulus  of  Natal  the  synonym  for  heaven  is 
^^ ubomi,"  which  means  "maggoty  meat."  The  natives  of  Siam  and 
Cambodia  prefer  to  keep  their  fish  until  it  has  begun  to  putrefy.  In 
some  parts  of  China  foul  eggs  several  months  old  are  enjoyed  as  a 
delicacy. 

Measly  swine  flesh  rapidly  decomposes,  and  the  various  processes 
of  drying,  smoking,  and  salting  still  leave  it  wholly  unfit  for  food. 

The  meat  of  very  young  animals  should  never  be  eaten,  and  the 
sale  of  young  or  "bob  "  veal  two  or  three  weeks  old  is  usually  pro- 
hibited by  law.  It  is  indigestible,  innutritious,  and  it  easily  decom- 
poses. 

Symptoms. — The  symptoms  of  meat  poisoning  from  these  vari- 
ous substances  are  substantially  the  saipe  in  each  case,  being  those 
of  severe  gastro-intestinal  irritation,  but  in  bad  cases  they  are 
accompanied  by  dangerous  collapse.  The  symptoms  may  follow 
almost  immediately  or  after  an  interval  of  several  days.  The  for- 
25 


352  DISEASES   CAUSED   BY   DIETETIC   ERRORS. 

mer  is  much  better  for  the  patient,  for  the  sooner  vomiting  and  diar- 
rhoea relieve  the  alimentary  canal  of  the  toxicogenic  material,  the 
greater  the  chance  of  recovery.  In  the  majority  of  cases  there  is  a 
latent  period  of  twelve  to  thirty-six  hours  between  the  ingestion  of 
the  spoiled  food  and  development  of  symptoms.  The  symptoms 
usually  begin  with  suddenness  and  violence,  but  they  may  be  pre- 
ceded by  malaise,  nausea,  lassitude,  and  mild  abdominal  cramps. 
The  sudden  onset  is  ushered  in  by  rigours  with  vertigo  or  faintness, 
or  violent  headache.  Exceptionally  there  is  dyspnoea,  and  there 
may  be  cold  perspiration  and  sudden  severe  pains  in  the  epigastrium 
or  in  the  thorax,  especially  between  the  shoulders.  Intense  thirst 
has  also  been  observed.  Soon  after  one  or  more  of  these  symptoms 
have  appeared  there  is  violent  colicky  pain  in  the  bowels,  accom- 
panied by  nausea,  retching  and  vomiting,  and  profuse  watery  diar- 
rhoea. There  is  an  extreme  degree  of  muscular  prostration  which 
comes  on  suddenly  and  prevents  the  patient  from  standing.  It  may 
be  due  to  the  abdominal  pain,  but  it  also  occurs  independently. 
The  tongue  is  dry  and  coated  with  a  thick  brownish-yellow  fur  on 
the  dorsum,  but  the  margins  are  of  a  bright  red  with  distinct 
papillae.  Fever  is  usually  present,  and  the  temperature  may  rise  to 
103.5°  or  i°4°  F.,  although  the  skin  may  feel  cold  and  moist.  The 
pulse  is  somewhat  accelerated  and  the  rate  may  reach  130  or  140. 

Occasional  symptoms  which  have  been  noted  by  Ballard  are 
severe  cramps  in  the  legs  and  arms,  convulsive  twitching  of  the  mus- 
cles of  the  face  and  hands,  stiffness  in  the  joints,  and  various  abnor- 
malities of  sensation,  such  as  numbness,  tingling,  and  flashes  of  heat 
and  cold  in  the  extremities.  There  may  also  be  drowsiness,  photo- 
phobia, and,  in  the  worst  cases,  insomnia,  nervous  excitement,  or 
mild  delirium.  If  the  poison  results  fatally,  the  prostration  in- 
creases, the  pulse  grows  rapid  and  feeble,  the  watery  evacuations 
are  uncontrollable,  and  rapid  emaciation  ensues.  The  patient  be- 
comes cyanotic  and  passes  into  a  state  of  collapse  resembling  that 
of  the  last  stage  of  cholera. 

The  poisoning  presents  all  degrees  of  severity  depending  on  the 
amount  of  the  tainted  food  which  has  been  taken,  the  nature  of  the 
putrefactive  process,  and  the  condition  of  the  alimentary  canal  at 
the  time.  In  mild  cases,  more  or  less  abdominal  pain,  vomiting, 
diarrhoea,  and  headache,  with  slight  prostration,  are  the  only  symp- 
toms. In  the  more  severe  cases,  if  convalescence  follows  the  attack, 
it  is  prolonged,  and  the  weakness  of  the  patient  may  be  fully  as 
great  as  after  some  of  the  severe  infectious  fevers  affecting  the  ali- 
mentary canal,  such  as  cholera  or  yellow  fever.  In  cases  in  which 
the  symptoms  develop  very  slowly,  after  an  interval  of  a  day  or 
more  the  nervous  symptoms  are  apt  to  predominate  over  those  of 
the    gastro-enteric   system.     There    are   painful    muscular   cramps, 


POISONING   BY   SHELLFISH   AND   FISH.  353 

dyspnoea,  aphonia,  delirium,  and   palpitation.     This  variety  of  poi- 
soning is  extremely  dangerous. 

Diag^nosis. — The  diagnosis  is  almost  always  obtainable  from  the 
history  of  the  case  in  connection  with  the  symptoms  above  de- 
scribed, and  when  canned  food  has  been  eaten,  the  only  difficulty 
consists  in  determining  whether  the  poisoning  is  the  result  of  eating 
tainted  meat  or  of  acute  metallic  poisoning  from  chloride  of  zinc, 
tin,  or  lead  used  in  the  process  of  tinning  and  soldering  the  cans 
(see  page  257). 

POISONING   BY    MILK,   CREAM,   ICE   CREAM,   AND   CHEESE. 

Poisoning  by  plain  milk  is  less  common  than  from  certain  vari- 
eties of  cheese  and  from  cream.  When  ice  cream  is  made  in  large 
quantities,  the  cream  is  allowed  to  accumulate,  and  if  a  portion  of  it 
becomes  infected  with  pathogenic  organisms  it  will  soon  convert 
the  whole  mass  into  highly  poisonous  material.  Vaughan  and  Novy 
in  this  country  have  thoroughly  studied  the  whole  subject  of  pto- 
maine poisoning,  and  Vaughan  has  isolated  from  cheese  and  ice 
cream  a  toxine  to  which  he  has  given  the  name  of  "  tyrotoxicon,"  and 
in  Michigan  in  i883-'84  nearly  three  hundred  instances  of  cheese 
poisoning  were  collected  by  him.  In  1890  he  isolated  three  proteid 
substances  from  germ  cultures  from  the  intestines  of  infants  having 
milk  infection.  The  symptoms  of  tyrotoxicon  poisoning  are  sub- 
stantially the  same  with  those  of  meat  poisoning,  consisting  of  se- 
vere gastro-intestinal  disturbance  with  collapse. 

This  toxine  produces  almost  immediately  after  ingestion  by  a 
previously  healthy  infant  violent  symptoms  of  cholera  morbus,  which 
prove  fatal  in  a  few  hours  unless  the  poison  can  be  eliminated  (see 
Cholera  Morbus  Treatment).  Of  this  poison  Vaughan  says:  "Post- 
mortem examination  shows  but  little  change.  [There  is  time  for 
but  little  in  fatal  cases.]  The  mucous  membrane  of  the  small  intes- 
tine is  bleached  and  softened,  and  possibly  deprived  here  and  there 
of  its  superficial  epithelium." 

The  poison  apparently  acts  somewhat  as  the  toxine  of  Asiatic 
cholera,  by  absorption  from  the  intestinal  wall,  and  by  violently  de- 
ranging the  nervous  and  vascular  systems,  producing  sudden  and 
extreme  loss  of  fluid  from  the  body  through  osmosis  into  the  in- 
testine. 

POISONING   BY   SHELLFISH   AND   FISH. 

Poisoning  by  shellfish  and  fish  results  from  infection  with  pto- 
maines developed  by  micro-organisms,  as  in  cases  of  milk  and 
meat  poisoning.  In  addition,  it  must  be  remembered  that  there  are 
a  number  of  persons  who,  from  idiosyncrasy,  possess  an  extreme 
degree  of  sensitiveness  to  the  action  of  shellfish  of  all  kinds.     To 


354 


DISEASES   CAUSED   BY   DIETETIC   ERRORS. 


such  persons  the  eating  of  clam  broth  or  raw  oysters,  crabs  or  lob- 
sters, may  give  rise  to  violent  outbreaks  of  urticaria  or  eczema,  or 
produce  severe  headache,  nausea,  and  vomiting.  It  is  scarcely 
probable  that  these  cases  are  due  to  the  same  source  as  those  of  true 
ptomaine  poisoning,  for  they  occur  when  the  shellfish  have  been 
eaten  in  perfectly  fresh  condition ;  the  symptoms,  moreover,  are 
usually  less  violent  than  those  caused  by  ptomaines,  and  similar 
effects  are  produced  in  some  people  by  certain  vegetables  and 
fruits,  like  the  strawberry.  Among  shellfish  the  mussel  furnishes 
the  most  violent  poison.  This  substance  Brieger  has  isolated  under 
the  name  of  "  mytilotoxine."  It  develops  particularly  in  the  liver  of 
the  animal.  The  intensity  of  the  poison  depends  somewhat  upon 
the  locality  in  which  the  animal  has  lived  and  fed.  The  same  mus- 
sels may  become  non-toxic  in  different  waters.  The  name  ichthys- 
mus  is  applied  to  fish  poisoning  in  general. 

Symptoms. — The  symptoms  of  poisoning  from  eating  raw  fish 
or  cooked  mussels  in  which  ptomaines  have  developed  are  somewhat 
different  from  those  of  meat  and  milk  poisoning  in  that  they  con- 
cern the  nervous  system  with  less  gastro-intestinal  disorder.  For 
this  reason  the  poison  is  very  much  more  dangerous,  and  fatal  cases 
have  been  known  to  result  two  hours  after  eating  mussels.  In  such 
instances  there  may  be  no  nausea,  vomiting,  or  fever,  but  there  is 
sudden  and  extreme  prostration,  with  numbness,  faintness,  coldness 
of  surface,  dilatation  of  the  pupils,  restlessness,  nervousness,  anxiety, 
and  a  feeble  and  very  rapid  pulse.  Decomposing  oysters  and  fish 
may  also  produce  symptoms  of  gastro-intestinal  poisoning  resem- 
bling those  from  the  use  of  bad  meat.  The  salted  sturgeon  which 
is  eaten  extensively  as  a  food  in  parts  of  Russia,  has  caused  death 
from  its  decomposition,  and  a  variety  of  fishes  both  in  European 
and  Eastern  waters  are  capable  of  developing  very  active  toxines. 

VI.  Food  containing  other  Poisons  than  Ptomaines. — 
Grain  Poisoning,  etc. 
It  sometimes  happens  that  flesh  becomes  poisonous  from  the  ani- 
mal having  fed  upon  some  noxious  substance  shortly  before  it  was 
killed.  The  flesh  of  pigs  fed  on  garbage  may  cause  diarrhoea 
(Parkes).  It  is  a  well-known  fact  that  the  flavour  and  digestibility 
of  game,  and  even  fish,  varies  much  with  "the  season  of  the  year  and 
the  consequent  nature  of  the  food  which  the  animal  has  had.  Oys- 
ters are  not  wholesome  food  from  May  to  September,  or  in  "  the 
months  without  an  R."  Cow's  milk  becomes  unhealthful  for  infants 
when  the  animal  eats  improper  food,  and  instances  have  been  re- 
ported— although,  fortunately,  they  are  very  exceptional — of  illness 
of  adults  caused  by  eating  meat  which  had  been  poisoned  during  the 
animal's  life,  as  in  the  case  of  a  sick  ox  to  which  a  large  dose  of 


GRAIN   POISONING. 


355 


tartar  emetic  was  given.  The  animal  died,  and  the  meat  subse- 
quently was  found  to  contain  enough  of  the  substance  to  severely 
poison  those  who  ate  it. 

Game  sometimes  disagrees  on  account  of  the  nature  of  the  food 
upon  which  the  animal  has  previously  been  living.  This  is  said  to 
be  particularly  true  of  the  grouse  in  various  parts  of  the  country  at 
some  seasons  of  the  year.  The  laurel  buds  act  in  this  manner. 
Hares  fed  upon  rhododendron  are  poisonous  (Letheby). 

A  curious  instance  of  poisoning  from  eating  turkey  meat  was 
lately  reported  by  Seelye,  of  Amherst,  Mass.  Several  young  women 
at  a  boarding  school  showed  symptoms  of  atropine  poisoning  after 
eating  a  bird  which  had  fed  upon  the  deadly  nightshade  berries. 

GRAIN   POISONING. 

Old  unripe  grain  and  mouldy  flour  develop  poisons  from  decom- 
position of  their  gluten. 

Ergotism. — The  fungus  known  as  ergot,  or  Claviceps  purpurea, 
grows  upon  rye,  and  in  Europe  the  careless  admixture  of  this  sub- 
stance with  grain  in  the  preparation  of  flour  has  several  times  re- 
sulted in  violent  symptoms  of  poisoning.  Collectively  the  symp- 
toms are  described  as  "  ergotism,"  and  they  are  commonly  divided 
into  two  varieties,  the  gangrenous  and  the  convulsive.  The  ergot- 
containing  flour  or  meal  must  have  been  eaten  for  a  considerable 
time,  as  a  rule,  in  order  to  develop  the  symptoms. 

Ergot  is  sometimes  employed  too  freely  in  medicine.  In  appro- 
priate cases  it  may  be  given  in  considerable  quantity  for  a  brief 
period  without  exciting  toxic  symptoms.  When,  however,  its  use  is 
prolonged  beyond  a  few  days,  serious  poisoning  results. 

In  the  gangrenous  form  of  ergotism  the  early  symptoms  are 
referable  to  local  vasomotor  disturbances,  affecting  principally  the 
extremities.  These  symptoms  are  anaesthesia,  numbness,  prickling 
pain,  and  spasmodic  twitching  of  the  muscles,  with  an  impeded  blood 
flow  due  to  vasoconstriction.  In  the  convulsive  variety  the  nerv- 
ous system  is  profoundly  disturbed.  After  a  period  of  indefinite 
symptoms,  such  as  lassitude,  headache,  and  prickling  sensations, 
spasms  of  the  muscles  with  contractures  begin.  The  spasms  may  be 
intermittent,  or  may  assume  a  tetanic  character,  lasting  sometimes 
through  many  days;  the  arms  are  strongly  flexed  and  the  legs  and 
toes  are  extended.  Spasmodic  rigidity  of  the  muscles  may  give 
place  to  violent  convulsions,  which  become  general  and  fatal.  There 
is  sometimes  slight  fever,  and  in  the  chronic  cases  melancholia  or 
dementia  results.  Delirium  also  is  sometimes  present.  In  cases  re- 
ported by  Siemens  and  Tuzzek  the  posterior  columns  of  the  spinal 
cord  were  found  sclerosed. 

Lathyrism. — A  grain  called  the  chick-pea  vetch  is  sometimes  used 


356 


DISEASES   CAUSED   BY   DIETETIC   ERRORS. 


for  the  adulteration  of  flour  from  various  cereals.  Several  varieties 
are  used  which  have  a  similar  effect  to  ergot  in  producing  a  condi- 
tion of  spastic  rigidity  in  the  lower  extremities.  This  form  of  poi- 
soning has  been  observed  in  India  by  James  Irving,  and  by  others  in- 
Italy  and  France.  It  is,  however,  rare,  and  but  little  is  known  as  to 
the  exact  nature  of  the  lesions. 

Pellagra. — Pellagra  is  a  functional  disturbance  caused  by  eating 
fermented  unripe  maize  or  Indian  corn,  made  into  polenta.  It  is  un- 
known in  this  country,  but  prevails  in  the  south  of  Europe,  in  por- 
tions of  Spain,  France,  and  Italy.  The  first  symptoms  noticed 
are  those  of  dyspepsia  with  more  or  less  nervousness,  insomnia,  and 
debility.  These  symptoms  are  followed  by  an  eruption,  the  pella- 
gral erythema,  which  develops  in  the  spring.  After  the  eruption  has 
lasted  for  some  time,  the  skin  becomes  very  dry  and  extensive  des- 
quamation ensues  accompanied  by  burning  pains,  or,  if  neglected,  the 
surface  may  become  incrusted  with  areas  of  suppuration.  With  the 
appearance  of  the  eruption  the  dyspeptic  symptoms  are  increased, 
and  there  may  be  salivation  and  severe  diarrhoea.  The  disease  lasts 
in  greater  or  less  severity  for  several  months  and  ends  in  slow  con- 
valescence, or  else,  in  the  worst  forms,  the  nervous  system  is  in- 
volved and  emaciation,  headache,  convulsions,  delirium,  and  paraly- 
sis of  the  legs  may  appear.  The  peasants  who  eat  this  spoiled  food 
sometimes  have  severe  attacks  in  successive  years,  and  melancholia 
and  suicidal  mania  have  been  observed  among  them.  There  are  no 
definite  lesions  other  than  those  of  malnutrition,  such  as  fatty  de- 
generation of  various  organs  (Arnold). 

The  disease  is  not  contagious,  and  it  is  said  to  be  preventable  by 
adding  salt  to  the  corn  meal ;  but  salt  is  a  Government  monopoly  in 
Italy.  The  peasants  resist  the  tax  upon  it,  and,  through  prejudice 
as  much  as  through  ignorance  and  poverty,  they  fail  to  make  use 
of  it. 

VII.  Food  Adulteration. 

Food  adulteration  consists  of:  i.  The  addition  of  deleterious 
substances.  2.  Fraudulent  substitution  of  cheaper  articles  of  food 
or  the  sale  of  food  not  as  fresh  or  good  as  it  is  represented. 

A.  J.  Wedderburn,  in  a  recent  report  to  the  United  States  Depart- 
ment of  Agriculture,  makes  the  statement  that  of  all  food  products 
sold  in  this  country,  15  per  cent  is  adulterated,  but  only  2  per  cent 
is  deleterious. 

With  the  exception  of  milk  and  alcoholic  beverages,  the  adultera- 
tion of  foods  in  the  United  States  is  of  comparatively  little  impor- 
tance from  any  harmful  influence  it  may  have  upon  health. 

Its  moral  are  often  worse  than  its  physical  aspects. 

In  this  country  almost  all  food  products  are  so  abundant  and 


FOOD  ADULTERATION.  357 

cheap  that  adulteration  would  be  too  expensive,  and  it  offers  small 
temptation  to  unscrupulous  dealers. 

The  object  of  adulteration  of  food — namel)',  to  cheapen  cost  of 
production — is  attained  by  (a)  increasing  the  bulk,  {i>)  altering  the 
appearance,  and  (c)  giving  false  strength. 

In  many  States  stringent  laws  have  been  enacted  against  all  adul- 
teration of  food  products,  beverages,  and  drugs,  but  the  ingenuity  of 
manufacturers  and  dealers  in  evading  them  necessitates  the  constant 
vigilance  of  the  experts  of  health  boards. 

Among  the  common  adulterations  may  be  mentioned  the  follow- 
ing :  Isinglass  adulterated  with  gelatin  ;  powdered  sugar  with  barium 
sulphate;  mustard  with  flour  and  turmeric  ;  distilled  coloured  vinegar 
sold  as  cider  vinegar ;  pickles  adulterated  with  iron  and  copper  (Mas- 
sachusetts State  Board  of  Health  Reports) ;  oleomargarine  sold  as 
butter;  ground  spices  are  adulterated  with  cocoanut  shells,  rice,  flour, 
and  ashes  (Ohio  Dairy  and  Food  Commission)  ;  water,  sugar,  and 
tartaric  acid  are  sold  as  lemonade.  Wines  and  liquors  are  sometimes 
adulterated  with  alum,  baryta,  caustic  lime,  salts  of  lead,  salicylic 
acid,  and  pigments,  especially  haematoxylon. 

Candies  are  adulterated  with  terra  alba,  kaolin,  and  various  pig- 
ments, and  the  different  chewing  gums,  gum  drops,  etc.,  are  largely 
made  with  petroleum-paraffin  products. 

Most  of  the  maple  sugar  sold  is  made  from  glucose,  and  maple 
sirup  is  also  derived  from  other  sugars  and  artificially  flavoured 
with  extract  of  hickory  bark  (Wiley). 

Cotton-seed  oil  is  often  sold  as  olive  oil. 

Nearly  half  the  liquid  honey  sold  is  adulterated  with  glucose. 

Cocoa  and  chocolate  are  adulterated  with  both  starch  and  sugar. 

Coffee  is  very  extensively  adulterated  with  sugar,  caramel,  pea 
meal,  chicory,  and  saccharine  extracts.  Even  coffee  berries  are 
artificially  made  in  moulds  out  of  mixtures  of  starch,  molasses,  or 
caramel,  chicory,  etc. 

Prof.  Chittenden,  as  a  result  of  elaborate  investigations  made 
with  a  view  to  determine  the  effect  upon  digestion  of  borax  and 
boric  acid  when  added,  as  they  often  are  to  preserve  foods,  con- 
cludes that  "borax  and  boric  acid,  when  present  in  moderate  quan- 
tities, can  have  little  or  no  deleterious  effect  upon  the  more  impor- 
tant chemical  processes  of  digestion.  On  the  contrary,  it  would 
appear  that  the  presence  of  these  agents  may,  in  some  cases  at 
least,  even  accelerate  the  normal  digestive  processes  of  the  alimen- 
tary tract." 

Pigments. — Artificial  colouring  matters  are  added  to  foods,  both 
to  intentionally  deceive  and  also  merely  to  make  different  sub- 
stances, such  as  preserved  green  vegetables,  candies,  or  confections, 
appear  more  attractive  to  the  eye. 


358 


DISEASES   CAUSED   BY    DIETETIC   ERRORS. 


Formerly  highly  injurious  copper  or  zinc  salts  were  much  used- 
to  colour  canned  peas  and  beans,  and  not  infrequently  they  were 
found  in  poisonous  quantities,  but  the  green  plant  pigment  chloro- 
phyll is  so  much  cheaper,  and  is  so  abundant  and  harmless,  that  it^ 
has  superseded  them  almost  entirely  since  its  introduction  for  this 
purpose  in  1877. 

Ultramarine  is  much  used  to  colour  sirups ;  eosin  and  many 
other  anilines  are  employed  in  the  manufacture  of  candies,  as  is  also 
cochineal. 

The  pigments  most  in  vogue  to  colour  butter  and  cream  are  tur- 
meric, saffron,  an  orange  pigment  from  the  stigmas  of  a  flower,  and 
annotto,  a  yellow  pigment  derived  from  the  fruit  of  a  South  Ameri- 
can tree.  Annotto  as  used  by  dairymen  to  colour  milk  and  cream  is 
not  harmful.  To  detect  it,  add  a  teaspoonful  of  baking  soda  to  a 
quart  of  the  milk,  and  immerse  in  it  a  strip  of  unglazed  paper.  In 
a  few  hours  the  latter  becomes  orange-coloured  if  annotto  is  present 
(Leffmann). 

Salicylic  Acid. — The  French  Commission  of  Public  Hygiene 
made  a  few  years  ago  an  exhaustive  investigation  of  the  subject  of 
adulteration  of  beer,  milk,  and  other  aliments  with  salicylic  acid, 
which  is  mainly  added  to  prevent  decomposition.  They  reported 
that  its  daily  use  in  the  quantities  employed  for  preservation  is  not 
harmful  to  healthy  persons,  but  if  renal  or  hepatic  disease  exists  it 
may  become  so,  for  under  these  conditions  it  is  not  promptly  elimi- 
nated. Used  in  any  considerable  quantity,  it  in  time  produces  anaemia, 
as.it  does  in  rheumatism. 

Wiley  found  salicylic  acid  in  seven  out  of  ten  samples  of  canned 
tomatoes  bought  in  markets. 

Vaseline  is  sometimes  used  to  adulterate  butter  for  making  pas- 
try and  cakes.  It  does  not  become  rancid,  and  is  therefore  difficult 
of  detection.     Fortunately,  it  is  not  especially  harmful. 

TIN   AND   LEAD   POISONING. 

Both  tin  and  lead  poisoning  may  occur  from  the  prolonged  use 
of  preserved  meats,  vegetables,  or  fruits.  In  tin  cans  the  lead  is  de- 
rived from  the  action  of  various  organic  acids  upon  the  solder  (which 
in  this  country  is  usually  50  per  cent  lead),  and  the  tin  used  for 
coating  the  inside  of  the  can  eventually  is  dissolved  in  a  similar 
manner  (see  also  Canning,  p.  257). 

Of  late  years  attention  has  been  directed  to  this  subject  by 
chemists,  and  a  number  of  cases  are  reported  from  time  to  time 
of  serious  metallic  poisoning.  As  a  general  rule,  if  the  canning  is 
properly  conducted  and  the  meats  or  vegetables  have  not  decom- 
posed, there  is  no  danger  in  their  use  provided  they  are  thoroughly 
cooked,  and  provided   also  that  the  cans  have  not  been   kept  too 


TIN  AND  LEAD   POISONING. 


359 


long.  The  amount  of  tin  dissolved  is  directly  proportionate  to  the 
age  of  the  contents  of  the  cans.  The  food  in  cans  that  have  been 
unopened  for  two  or  three  years  is  very  apt  to  produce  poisonous 
effects  (Dr.  van  Hamel  Roos,  Rev.  Intern,  des  Falsifications,  4, 
10,  179). 

Prof.  Bettink  declares  that  malic  acid  is  the  solvent  of  the  tin 
when  fruits  and  vegetables  are  canned. 

In  1880  Hehner  examined  many  canned  foods,  and  found  tin  pres- 
ent, in  most  of  them  as  a  stannous  hydrate,  which  existed  in  sufficient 
quantity  to  be  fatal  when  given  to  Guinea  pigs. 

Ungar  and  Bodlander  in  1883  reported  a  number  of  cases  of  poi- 
son from  canned  asparagus.  Tin  present  in  such  food  in  an  insoluble 
form  may  be  dissolved  and  absorbed  during  digestion. 

Professor  Beckurts  reported  at  the  Congress  of  German  Physi- 
cians in  Heidelberg,  September  25,  1889,  that  a  sulphate  of  tin  is 
formed  by  the  action  of  vegetable  albuminoids  or  of  meat  albumin 
on  the  can.  This  is  very  liable  to  take  place  with  canned  asparagus, 
and  two  recent  cases  of  severe  poisoning  of  this  nature  have  come 
under  my  personal  notice.  Violent  gastro-intestinal  symptoms  oc- 
curred, such  as  severe  vomiting  and  diarrhoea,  accompanied  by  faint- 
ness  and  vertigo.  The  symptoms  came  on  two  or  three  hours  after 
eating  the  asparagus  from  cans  which  had  been  kept  for  a  long  time. 

Johnson  (in  The  Medico-Legal  Journal,  vol.  iii,  p.  53)  reports 
cases  of  dangerous  poisoning  from  eating  tinned  tomatoes  which 
were  accompanied  by  symptoms  of  violent  gastritis,  stupor,,  and 
coma. 

Winckel  reported  to  the  Congress  of  Industrial  Hygiene  at  Am- 
sterdam in  September,  1890,  that  270  soldiers  had  been  made  ill 
from  eating  lettuce  and  meat  preserved  in  tins.  In  their  cases  it  was 
estimated  that  the  quantity  of  tin  in  solution  was  from  19  to  72  mil- 
ligrammes per  kilogramme.  Dr.  Roos  advises  the  coating  of  such 
cans  on  the  inside  with  insoluble  varnish,  which  prevents  the  albu- 
minoids or  vegetable  acids  from  coming  in  contact  with  the  tinned 
surface  and  dissolving  the  metal.  He  found  upon  opening  a  can  of 
asparagus  preserved  for  thirty-one  years  that  the  inside  tin  coating 
was  wholly  dissolved  in  the  liquid.  A  can  of  beef  preserved  for  eight 
years,  weighing  976  grammes,  contained  77  milligrammes  of  oxide  of 
tin,  and  a  can  of  asparagus  preserved  only  four  months  contained  11 
milligrammes  of  oxide  of  tin  and  6  of  copper.  Preserved  apples, 
corn,  apricots,  meats,  and  soups  have  also  all  been  found  to  possess 
the  same  solvent  action  upon  tin  cans.  This  is  almost  entirely  pre- 
vented in  those  instances  in  which  a  coating  of  varnish  has  been  put 
over  the  tinned  surface. 

Pears  cooked  in  a  tin  stewpan  have  been  known  to  cause  severe 
poisoning. 


360 


DISEASES  CAUSED   BY  DIETETIC   ERRORS. 


In  1883,  150  cases  of  severe  metallic  poisoning  occurred  among 
the  soldiers  of  a  Tyrolese  regiment  who  ate  food  from  a  tin-lined 
copper  kettle. 

In  general,  food  cooked  or  allowed  to  stand  for  any  length  of 
time  in  either  brass  or  copper  vessels  not  kept  absolutely  clean  is 
dangerous  to  life. 

VIII.  Food  containing  Micro-organisms. 

Recent  developments  in  the  study  of  micro-organisms  conducted 
within  the  past  decade  have  demonstrated  very  clearly  the  dangers 
of  infection  upon  a  large  scale  from  consumption  of  meat,  milk,  and 
other  foods  contaminated  by  the  germs  of  infectious  diseases. 

MILK   INFECTION. 

Milk  is  an  admirable  culture  medium  for  a  great  variety  of  germs, 
and  some  bacilli,  like  those  of  typhoid  fever  and  tuberculosis,  thrive 
particularly  well  in  it.  Moreover,  its  abundant  and  varied  proteid 
material  furnishes  substance  out  of  which  to  develop  powerful  toxines 
for  absorption. 

The  following  are  the  chief  diseases  whose  germs  are  capable  of 
being  sometimes  conveyed  by  milk  :  Tuberculosis,  typhoid  fever, 
cholera,  diphtheria,  scarlet  fever. 

Milk,  and  food  in  general,  should  never  be  kept  standing  in  an 
ice  box  or  cellar  near  an  open  or  defective  drain,  as  it  becomes 
rapidly  tainted  in  noxious  air. 

TUBERCULAR   INFECTION    THROUGH    MILK   AND   MEAT. 

Tubercular  Milk  Infection. — This  matter  is  of  special  impor- 
tance in  regard  to  the  danger  of  conveying  tuberculosis  to  infants 
through  raw  milk.  That  this  often  happens  is  abundantly  proved, 
and  State  boards  of  health  in  this  country  are  everywhere  endeavour- 
ing to  secure  proper  legislative  authority  to  inspect  and  condemn 
tuberculous  cattle. 

Milk  infected  with  tubercle  bacilli  when  fed  to  animals  has  been 
shown  to  produce  primary  intestinal  and  mesenteric  tuberculosis,  and 
this  is  equally  true  of  infants.  Cow's  milk  may  contain  tubercle 
bacilli  even  when  the  disease  is  located  in  the  lungs  of  the  animal 
(Ernst).  It  is  possible  that  this  is  the  dase  with  the  milk  of  tubercu- 
lar mothers,  although  it  is  not  yet  an  established  fact.  The  danger 
to  the  infant  is  less  in  such  cases,  for  the  disease  in  the  mother  is 
usually  recognised  in  time  to  discontinue  breast  nursing. 

It  has  been  estimated  in  regard  to  the  Eastern  States  that  15  per 
cent  of  the  common  dairy  stock  is  tubercular,  and  the  "  virulence  is 
retained  in  cream  and  butter  "  (Osier).     Stall-fed  animals  who  live 


TYPHOID   AND   CHOLERA   INFECTION.  361 

in  filthy  barns  and  get  but  little  exercise  show  the  largest  percentage 
of  infection.  In  healthy  adults  the  gastric  juice  may  succeed  in  de- 
stroying tubercle  bacilli  swallowed  with  such  food,  and  no  doubt  it 
often  does  so.  Fortunately  the  milk  of  all  tuberculous  cows  does  not 
contain  the  bacilli,  but  it  is  almost  certain  to  do  so  when  the  udders 
become  involved  in  the  disease. 

In  infants  who  live  largely  upon  raw  milk,  and  whose  gastric 
digestion  is  less  vigorous  than  that  of  adults,  mesenteric  tubercu- 
losis is  relatively  more  common. 

Tubercular  Meat  Infection. — Tubercular  meat  usually  proves 
less  virulent  than  raw  milk,  probably  because  it  is  subjected  to 
thorough  heat  in  cooking,  but  all  the  bacilli  are  not  invariably  killed 
by  imperfect  cooking,  and  infected  meat  or  milk  should  on  no  account 
be  eaten.  This  fact  is  being  gradually  appreciated  by  the  public,  and 
meat  inspection  at  abattoirs  is  now  much  better  regulated  j?y  law  and 
supervised  by  local  health  boards  than  formerly ;  but  Billings  says 
that  "  probably  one  half  of  one  per  cent  of  the  beef  sold  in  market 
comes  from  animals  in  whom  tubercle  existed  at  the  time  of  death." 

All  slaughtering  should  be  done  in  public  abattoirs  under  compe- 
tent inspection,  and  not  only  should  the  animals  be  examined  before 
killing,  but  the  meat  should  be  inspected  afterwards. 

The  Bacillus  tuberculosis  has  been  found  not  only  in  the  meat  or 
muscle  of  the  animal  butchered,  but  in  the  liver,  kidneys,  and  other 
viscera.  It  has  also  been  seen  in  peripheral  caseous  nodules  grow- 
ing upon  fowls  (Sibley),  and  barnyard  fowls  have  been  known  to  eat 
tuberculous  sputum  carelessly  expectorated  within  their  reach. 

Other  Infections. — Meat  from  animals  dead  of  various  acute 
diseases  is  sometimes  eaten,  and  if  well  cooked  it  is  usually  harmless, 
but  it  is  not  good  food,  and  no  part  of  any  animal  suffering  from  the 
foot-and-mouth  disease  (or  cattle  plague),  rabies,  glanders,  actinomy- 
cosis, anthrax,  septicaemia,  swine  plague,  sheep  or  cow  pox,  pneumo- 
nia, trichiniasis,  or  tuberculosis  should  ever  be  eaten. 

TYPHOID   AND   CHOLERA   INFECTION. 

Typhoid  infection  is  undoubtedly  conveyed  through  milk  which 
has  been  diluted  with  water  infected  from  a  barnyard  well  or  cess- 
pool, or  which  has  been  placed  in  cans  rinsed  in  such  water.  Mr. 
Hankin  (Indian  Medical  Gazette,  1894)  describes  cases  of  this  fever 
derived  from  eating  dahi,  a  curdled  milk  made  by  Indian  confec- 
tioners. 

Over  two  hundred  cases  from  milk  infection  occurred  at  Stam- 
ford, Conn.,  in  May,  1895. 

Typhoid  infection  through  contaminated  drinking  water  has  been 
already  mentioned  (page  31).  Even  brushing  the  teeth  with  such 
water  or  using  it  as  ice  may  convey  the  bacilli  into  the  body. 


362 


DISEASES  CAUSED   BY   DIETETIC   ERRORS. 


INFECTION    WITH     TYPHOID-FEVER    GERMS    THROUGH    EATING 

OYSTERS. 

An  epidemic  of  typhoid  fever  occurred  at  Wesleyan  University 
in  the  latter  part  of  November,  1894,  which  affected  only  certain  stu- 
dents to  the  number  of  thirty,  who  had  attended  college-society  sup- 
pers and  ate  raw  oysters.  A  very  thorough  investigation  was  made 
by  Prof.  H.  W.  Conn  (Medical  Record,  December  15,  1894)  into  the 
aetiology  of  the  epidemic,  and  the  following  account  of  it  was  pub- 
lished in  the  New  York  Times  on  November  20,  1894: 

"  The  investigators  at  first  ascertained  that  neither  the  water  of 
the  college  well  nor  the  milk  supply  had  been  the  agent  of  infection. 
Six  college  societies  had  given  initiation  suppers.  All  of  the  oysters 
eaten  at  these  suppers  had  come  from  one  dealer,  who  had  obtained 
them  from  one  oyster  grower.  At  three  of  these  suppers  raw  oysters 
were  served,  and  all  of  the  thirty  victims  had  partaken  of  the  oysters 
in  this  condition ;  no  one  of  those  present  at  the  other  three  sup- 
pers, where  only  cooked  oysters  were  served,  was  attacked  by  the 
disease.  These  facts  indicated  that  the  germs  of  typhoid  had 
been  conveyed  in  the  water  and  other  matter  which  accompanied 
the  raw  oysters.  How  had  that  water  and  other  matter  become 
infected  ? 

"The  oyster  grower,  who  lives  on  the  shore  of  the  Quinnipiac 
River,  a  stream  which  flows  into  New  Haven  harbour,  had  been  in 
the  habit  of  laying  down  his  oysters  for  a  day  or  two  in  the  river, 
after  taking  them  from  the  deep  salt  waters  of  the  Sound  and  before 
putting  them  on  the  market.  At  about  the  time  when  the  first  cases 
appeared  at  the  university  his  wife  died  of  typhoid  fever.  His 
daughter  had  been  ill  with  the  same  disease.  The  oysters  which 
were  sold  to  the  students  had  been  bedded  temporarily  in  the  river 
at  a  point  near  the  place  where  a  short  drain  from  his  house  dis- 
charges into  the  stream.  The  water  became  infected  by  the  flow 
from  the  drain,  and  when  the  qysters  were  taken  up  the  liquid  and 
other  matter  which  accompanies  oysters  so  dislodged,  either  on  the 
outside  of  the  shell  or  inside  of  it,  contained  the  germs  of  typhoid. 
Cooking  killed  these  germs,  but  the  raw  oysters  carried  to  those  who 
ate  them  a  dose  of  typhoid  poison.  It  is  reported  that  several 
recent  cases  of  typhoid  in  New  Haven  have  been  traced  to  infection 
thus  conveyed  by  oysters  from  the  same  river." 

It  has  generally  been  believed  heretofore  that  typhoid  bacilli  do 
not  develop  in  salt  water,  but  the  circumstantial  evidence  points, 
strongly  to  their  having  existed  in  the  brackish  water  above  de- 
scribed. 

Two  fatal  cases  of  typhoid  fever  have  lately  been  reported  in 
Berlin  as  due  to  infection  from   raw  oysters.     Sir  William    Broad- 


FOOD    INFECTION   THROUGH    FLIES. 


363 


bent  reported  in  the  British  Medical  Journal  ten  cases  which  he  saw 
during  November  and  December,  1894,  and  attributed  to  the  same 
origin. 

It  is  possible,  although  it  is  not  definitely  proved,  that  typhoid 
bacilli  may  be  conveyed  upon  raw  vegetables  and  fruits  which  have 
been  washed  in  contaminated  water.  It  is  known  that  cholera  germs 
are  conveyed  in  all  of  these  ways.  From  this  reason,  as  well  as 
from  the  necessity  of  avoiding  diarrhoea,  it  is  customary  to  advise 
against  the  use  of  all  raw  fruits  and  vegetables  during  the  preva- 
lence of  a  cholera  epidemic. 

DIPHTHERIA   AND   SCARLATINA. 
Diphtheria  germs,  and  even  those  of  scarlatina,  can  be  conveyed 
in  milk  should  they  have  access  to  it.     Several  epidemics  of  both 
diseases  have  been  traced  among  families  employing  in  common  a 
milkman  whose  children  at  home  had  one  or  other  disease. 

FOOT-AND-MOUTH  DISEASE. 
The  foot-and-mouth  disease  may  be  propagated  from  the  use 
of  milk  from  an  infected  cow.  Sometimes  this  milk  is  of  a  bad 
taste  and  odour,  or  it  may  even  be  mixed  with  blood  or  pus  if  the 
nipples  are  excoriated  or  if  the  udders  are  inflamed.  In  other  cases 
the  milk  appears  normal,  but  when  boiled  coagulates  readily  into 
small  flocculi  in  a  bluish  whey.  Such  milk  is  rendered  innocuous 
by  the  process  of  boiling.  Children  are  more  apt  to  contract  the 
disease  in  this  way  than  are  adults,  owing  to  their  greater  con- 
sumption of  cow's  milk. 

FOOD   INFECTION    THROUGH    FLIES.  . 

The  importance  of  preventing  food  infection  through  the  agency 
of  common  house  flies  is  just  beginning  to  be  appreciated.  These 
insects  are  admirably  adapted  to  convey  infection  from  their  great 
numbers  and  incessant  activity,  as  well  as  their  numerous  feet, 
capacious  intestines,  their  frequent  evacuations,  and  disgusting  habits 
of  alighting  and  feeding  upon  sputum,  manure  heaps,  and  all  animal 
discharges.  When  fed  on  tubercular  sputum  the  bacilli  have  been 
discovered  alive  in  their  intestines,  and  cholera  germs  have  been 
found  adhering  to  their  feet  by  which  they  are  easily  transported 
from  a  choleraic  stool  to  a  piece  of  bread  or  a  raw  fruit  or  vegetable, 
destined  in  turn  to  infect  the  first  person  who  is  unlucky  enough  to 
eat  it.  During  the  recent  cholera  epidemic  in  Hamburg  Dr.  Sim- 
monds  found  comma  bacilli  in  the  intestines  of  flies  in  the  post- 
mortem room  where  dead  cholera  patients  were  examined.  The 
bacilli  remained  one  and  a  half  hour  in  the  flies — time  enough  to  be 
carried  a  long  distance  or  to  be  widely  distributed.    When  the  matter 


364 


DISEASES   CAUSED   BY   DIETETIC   ERRORS. 


is  further  investigated  it  will  doubtless  be  shown  that  other  kinds 
of  infection  are  often  spread  by  the  medium  of  these  vulgar  pests. 
Ordinary  pus  infection  is  readily  carried  by  flies. 

IDIOSYNCRASIES   IN   REGARD   TO   FOOD. 

Idiosyncrasies  are  found  to  exist  with  some  persons  in  regard  to 
special  articles  of  food,  and  these  cannot  be  readil)^  explained.  As 
a  rule,  if  marked,  they  extend  throughout  life,  but  it  is  not  seldom 
the  case  that  some  people  pass  through  periods  when  a  particular 
article  of  food  disagrees  with  them  which  they  have  been  previously 
able  to  eat  with  impunity.  Some  are  unable  to  digest  milk  and  are 
immediately  nauseated  or  made  "bilious"  by  it,  while  others  cannot 
eat  eggs,  and  yet  can  drink  milk,  while  some  cannot  take  either. 
Some  can  eat  the  white  and  not  the  yolk  of  eggs.  Others,  again, 
cannot  eat  fat  in  any  form  or  are  unable  to  digest  some  one  variety 
of  fat,  especially  hot  mutton  fat.  Some  few  persons  acquire  a  head- 
ache whenever  they  eat  butcher's  meat  in  excess.  Among  the  com- 
moner idiosyncrasies  of  diet  are  the  revolt  of  the  system  which 
occurs  from  the  use  of  shellfish  of  all  kinds,  but  especially  lobsters, 
and  from  strawberries.  Fothergill  reported  the  case  of  a  lady  who 
all  her  life  was  unable  to  drink  coffee,  of  which  she  was  very  fond, 
without  having  diarrhoea  from  it  within  an  hour  or  two. 

Such  idiosyncrasies  are  not  infrequently  hereditary,  and  may 
affect  several  members  of  one  family.  They  are  wholly  independ- 
ent of  ordinary  dyspeptic  conditions,  and  may  be  present  in  those 
whose  digestive  organs  are  exceptionally  robust. 

X,  Alcohol  Poisoning. — Alcoholism. — Delirium  Tremens. 

The  position  of  alcohol  as  both  a  food  and  a  stimulant  has  al- 
ready been  fully  discussed  in  connection  with  its  physiological  and 
dietetic  action  (page  209). 

alcohol  poisoning. 

The  effects  of  poisoning  by  alcohol  differ  according  as  they  are 
acute  or  chronic,  and  according  to  the  previous  alcoholic  habits  of 
the  patients.  Habitual  drinkers  easily  consume  quantities  of  raw 
spirits  which  might  prove  fatal  if  drunk  by  one  not  inured  to  their 
use.  Men  have  been  known  to  drop  dead  a  few  moments  after 
quickly  drinking  a  pint  or  more  of  whisky  on  a  wager. 

Alcohol  when  used  to  excess  as  a  stimulant  differs  somewhat 
from  ether  and  chloroform  in  the  fact  that  its  effects  come  on  more 
slowly,  as  manifested  by  the  increased  mental  excitement  of  intoxi- 
cation. The  stage  of  insensibility  and  final  stupor  or  coma  develops 
later  after  slowly  taking  large  quantities  of  alcohol,  and  is  of  longer 


ALCOHOL   POISONING.  365 

duration.  Patients  suffering  from  alcoholic  coma  are  always  in  danger 
of  heart  failure  from  paralysis  of  that  organ,  which  forms  no  excep- 
tion to  the  general  rule  that  overstimulation  of  any  muscle  produces 
exhaustion  and  paresis.  When  in  this  condition,  however,  they  are 
fortunately  incapacitated  from  making  any  sudden  or  violent  exer- 
tion, and  in  acute  cases  alcohol  is  eliminated  with  considerable 
rapidity  from  the  various  excretory  organs  of  the  body,  especially 
the  kidneys,  in  the  form  of  waste  matter,  which  it  produces. 

The  continued  use  of  strong  spirits,  as  well  as  the  occasional  use 
of  alcohol  in  excess,  almost  invariably  results  after  some  time  in  the 
establishment  of  chronic  gastric  catarrh,  which  is  characterised  by 
the  formation  of  thick,  ropy  mucus,  thickening  and  hardening  of 
the  gastric  mucous  membrane,  with  atrophy  of  the  gastric  glands. 
There  is  always  malfermentation  with  more  or  less  acidity  and 
heartburn  and  considerable  nausea,  especially  in  the  morning,  when 
the  mucus  or  products  of  indigestion  have  accumulated  overnight. 
There  is  also  an  increased  production  of  connective  tissue  in  the 
stomach  wall.  The  effects  of  chronic  alcoholism  upon  the  alimen- 
tary canal  are  chiefly  manifested  in  the  stomach,  although  the  intes- 
tine may  share  in  the  pathological  changes.  This  is  due  to  the  fact 
that  the  alcohol  reaches  the  stomach  in  a  more  concentrated  form, 
and  that  being  very  diffusible  it  is  absorbed  in  great  part  without 
entering  the  intestine. 

In  addition  to  the  local  gastric  catarrh  and  inflammation  which  it 
may  produce,  alcohol  gradually  alters  various  viscera,  causing  cir- 
rhosis of  the  liver,  nephritis,  chronic  endarteritis,  etc. 

In  chronic  alcoholism  the  intense  craving  for  alcohol  in  any 
form  tends  to  weaken  and  overcome  the  will  power  and  debase  the 
moral  nature  of  the  individual,  and  those  who  are  afflicted  by  this 
habit  very  often  drink  periodically — that  is,  the  intervals  between 
their  excesses  may  be  prolonged  for  one  or  several  months,  during 
which  time  they  touch  no  alcohol  in  any  form,  and,  indeed,  in  some 
cases  they  may  have  a  positive  loathing  for  it.  The  very  sight  of  it 
nauseates  them.  The  craving  then  returns  and  becomes  so  irresisti- 
ble that  if  they  cannot  obtain  liquor  they  have  been  known  to  drink 
raw  alcohol  from  spirit  lamps  or  in  any  shape  in  which  they  can  ob- 
tain it.  The  craving  consists  partly  of  a  special  appetite  for  liquor 
in  the  stomach,  and  in  part  of  the  general  irresistible  desire  of  the 
system,  which  is  somewhat  akin  in  its  effect  to  intense  hunger,  al- 
though the  effect  on  the  will  power  is  more  disastrous. 

The  evil  results  of  excessive  indulgence  in  alcohol  are  strikingly 
shown  by  its  effect  upon  liquor  dealers,  the  mortality  among  whom, 
from  various  diseases,  as  compared  with  that  of  other  men,  bears  the 
ratio  3  to  2.  When  a  similar  comparison  is  made  in  regard  to  the 
mortality  of  liquor  dealers   from  special  diseases,  the  result  is  still 


366  DISEASES   CAUSED   BY   DIETETIC   ERRORS. 

more  striking;  thus  for  liver  diseases  the  ratio  is  6  to  i,  for  nervous 
diseases  nearly  2  to  i,  and  for  alcoholism  5.5  to  i. 

Dietetic  Treatment  of  Mild  Cases. — In  the  milder  cases 
characterised  by  nervousness,  muscular  tremors,  indigestion,  dys- 
pepsia, a  foul  breath,  coated  tongue,  and  urine  loaded  with  urates 
or  crystalline  deposits,  if  the  patient  can  be  induced  to  stop  all 
alcoholic  drink  and  take  abundant  water  or  alkaline  effervescing 
waters  (Vichy,  Seltzer,  Apollinaris,  etc.),  together  with  a  proper  diet, 
much  can  be  done  to  ward  off  an  acute  attack.  A  very  good  example 
of  the  appropriate  diet  is  the  following  from  Foods  and  Diet- 
aries : 

'■^Breakfast. — A  lightly  boiled  Q.g%,  or  a  little  bit  of  whitefish  or 
of  bacon,  or  a  light  savoury  omelet;  toast,  or  bread  and  butter;  a 
cup  of  weak  tea  or  of  coffee  and  milk. 

'■'■Early  Dinner,  i  o'clock. — A  slice  of  roast  mutton,  or  the  wing  of 
a  chicken,  or  a  plain  cutlet,  with  a  spoonful  of  mashed  potato  and 
some  well-boiled  green  vegetable.  A  few  spoonfuls  of  any  plain 
milk  or  bread  pudding,  with  occasionally  some  stewed  fruit.  Bever- 
age.— A  glass  of  plain  or  aerated  water,  to  be  taken  slowly  towards 
the  close  of  the  meal. 

^'■Afternoon. — A  cup  of  tea  with  milk  may  be  allowed,  with  toast 
or  rusk. 

^^  Supper,  7.30. — A  light  meal  of  fresh  fish,  or  of  bird,  or  of  calf's 
head,  or  of  tripe,  with  dry  boiled  rice  or  bread.  Beverage. — Small 
glass  of  milk  and  soda  water.." 

In  cases  of  periodic  alcoholism,  in  which  the  patient  has  no  crav- 
ing for  drink  between  his  attacks,  it  is  best  to  recommend  for  the 
intervals  a  non-stimulating  diet,  avoiding  condiments  and  richly 
cooked  or  highly  seasoned  food  of  all  sorts.  Fruits,  plainly  cooked 
cereals,  and  vegetables  should  constitute  the  staple  diet,  and  animal 
food  should  be  eaten  only  in  moderation. 

In  some  of  these  cases  overindulgence  in  food  excites  the  crav- 
ing for  alcohol. 

Dietetic  Treatment  of  Severe  Cases. — The  treatment  of  the 
severer  cases,  in  which  dyspeptic  or  gastro-intestinal  symptoms  pre- 
dominate, but  in  which  delirium  tremens  is  not  necessarily  present, 
is  mainly  that  of  gastric  catarrh,  described  elsewhere.  It  must  be 
adapted  to  the  degree  of  inflammatory  or  cirrhotic  changes  which 
have  already  taken  place  in  the  different  organs.  The  patients  usu- 
ally feel  much  worse  in  the  mornings,  having  nausea  and  vomit- 
ing or  loathing  for  food,  but  later  in  the  day  they  may  recover 
considerable  appetite  and  power  of  digestion.  Advantage  should  be 
taken  of  this  fact  in  feeding  them.  The  following  menu  from  Foods 
and  Dietaries  is  very  well  adapted  to  this  stage  of  chronic  alco- 
holism : 


DELIRIUM   TREMENS.  367 

^'■Breakfast,  say  8  o  clock. — A  cup  of  weak  tea  with  an  t%g  beaten 
up  in  it,  and  a  slice  of  toast. 

"■  Second  Meal,  10.30.— A  cupful  of  good  meat  soup,  thickened,  or 
a  cup  of  peptonised  milk,  warmed,  with  toast  or  rusk. 

"  Early  Dinner,  i  0  clock. — A  tablespoonful  of  pounded  meat  on 
toast,  or  a  small  teacupful  of  fresh  meat  juice,  with  fingers  of  toast. 
A  couple  of  spoonfuls  of  sago,  custard,  or  tapioca  pudding.  Bever- 
age.—WaXi  a  tumblerful  of  milk  and  soda  water  (equal  parts). 

''Afternoon  Tea,  4.30. — A  cup  of  weak  tea  or  of  cocoa  nibs,  with 
rusk  or  a  plain  biscuit. 

''Evening  Meal,  7  o'clock.— K  cup  of  soup  or  of  mutton  broth,  as 
at  the  forenoon  meal. 

"  9.30  or  10. — A  cup  of  peptonised  milk  and  a  slice  of  thin  bread 
and  butter. 

"  Eood  During  the  Night. — In  case  of  wakefulness  there  should  be 
within  reach,  and  arranged  so  as  to  be  readily  warmed,  peptonised 
milk." 

DELIRIUM   TREMENS. 

Delirium  tremens  is  a  condition  of  active  maniacal  excitement 
which  in  its  worst  form  is  accompanied  by  intense  general  nervous 
excitement,  muscular  weakness,  and  hallucinations,  chiefly  of  sight 
and  hearing,  of  a  terrifying  or  disgusting  nature. 

Delirium  tremens  is  sometimes  excited  by  a  temporary  debauch, 
but  as  a  rule  this  results  in  a  condition  of  coma  rather  than  maniacal 
excitement.  Delirium  tremens  is  much  more  characteristic  of  habitual 
alcoholism. 

In  the  earlier  stages  the  heart  action  may  be  apparently  vigor- 
ous and  the  pulse  full  and  bounding,  but  the  heart  is  very  apt  to  be- 
come suddenly  exhausted  and  cardiac  failure  is  the  chief  danger  to 
be  feared. 

Dietetic  Treatment. — The  indications  for  dietetic  treatment 
are  to  make  sure  that  the  alimentary  canal,  which  has  been  previ- 
ously  disordered  and  congested,  if  not  inflamed  by  the  excessive 
irritation  of  strong  alcoholic  drink,  is  emptied  of  any  accumulation 
of  abnormally  fermenting  food.  In  the  earlier  stages  brisk  purga- 
tion or  an  evacuant  enema  should  be  given.  If  the  stomach  is  over- 
loaded with  improper  food,  free  vomiting  should  be  produced  by 
ipecac,  provided  the  condition  of  the  patient  is  sufficiently  vigorous 
to  warrant  this  procedure.  Large  draughts  of  water,  aerated  and 
saline  waters,  should  be  taken  to  promote  the  activity  of  the  kidneys 
and  to  dilute  the  poison  in  the  system.  The  alimentary  canal  having 
thus  been  emptied  of  fermentation  products,  it  becomes  necessary  to 
support  the  patient's  strength  with  abundant  nourishment.  The 
appetite  for  food  is  usually  entirely  absent,  being  replaced  by  that 
26 


368 


DISEASES  CAUSED   BY  DIETETIC   ERRORS. 


for  drink,  but  the  patient  must  be  urged  to  take  all  the  nourishment 
possible,  and  to  this  end  it  may  be  given  in  fluid  form  in  smaH,  fre- 
quent doses.  The  food  should  be  stimulating  and  predigested.  If 
there  is  much  gastro-intestinal  irritation,  pancreatinised  milk,  strong 
meat  soups,  beef  tea  with  dropped  eggs  added  to  it,  and  egg  albumen 
may  all  be  given.  The  mucous  surface  of  the  stomach  has  been 
long  accustomed  to  the  stimulating  effect  of  strong  alcohol,  and  if 
this  be  suddenly  and  completely  removed,  gastric  discomfort  and 
craving  for  drink  become  intolerable.  This  condition  is  often  re- 
lieved by  using  strong  spices  or  condiments,  such  as  ginger  or  Cay- 
enne pepper,  in  quantities  which  would  be  injurious  to  a  normal 
stomach,  and  might  possibly  produce  gastritis.  These  substances 
may  be  added  to  food  and  non-alcoholic  drink,  although  the  stom- 
ach may  be  actually  inflamed.  Experience  proves  that  highly  sea- 
soned food  is  sometimes  borne  with  the  effect  of  diminishing  the 
suffering  of  the  patient.  This  applies,  of  course,  only  to  very  robust 
cases,  in  which  an  otherwise  vigorous  constitution  has  been  abused 
by  excessive  indulgence  in  drink,  and  the  gastric  stimulant  should 
not  be  long  continued.  In  this  variety  of  cases  the  quantity  of  food 
which  the  patient  is  encouraged  to  take  need  only  be  limited  by  the 
ability  to  digest  it,  for  the  digestive  organs  can  be  kept  fairly  active 
without  being  overloaded  to  the  extent  of  exciting  abnormal  fermen- 
tation. The  nervous  system  is  always  strengthened  and  soothed  by 
abundant  nourishment. 

Ginger  ale  constitutes  a  very  serviceable  non-alcoholic  beverage, 
which  in  part  relieves  the  craving  for  stronger  drink.  It  may  be 
drunk  in  considerable  quantity,  and  it  possesses  the  advantage  of 
being  somewhat  laxative,  diuretic,  and  mildly  stimulating  to  the 
stomach.  Care  should  be  taken  to  obtain  a  pure  article,  as  there  is 
much  inferior  ale  in  market. 

It  is  well  known  that  persons  who  for  many  years  have  indulged 
excessively  in  spirituous  drinks  are  very  apt  to  develop  delirium 
tremens  if  taken  suddenly  ill,  or  if  they  sustain  an  injury  such  as  a 
fracture,  although  they  may  have  drunk  no  liquor  for  many  weeks. 
In  such  cases  the  patient's  life  is  in  serious  danger  and  it  may  be 
necessary  to  give  more  alcohol  to  maintain  the  accustomed  influence. 
The  conditions  here  to  be  met  are  very  different  from  those  resulting 
from  an  ordinary  debauch,  when  liquor  should  be  entirely  with- 
held. 


PART   VII. 
ADMINISTRATION   OF   FOOD   FOR   THE  SICK. 


METHODS  OF    FEEDING  THE  SICK. 

General  Rules. 

In  no  branch  of  her  work  can  the  nurse  be  of  more  service  than 
in  her  ability  to  feed  a  very  sick  patient  properly.  There  are  many 
details  which  can  only  be  mastered  by  extensive  bedside  experience 
and  close  observation,  and  so  much  depends  upon  tact  and  discretion, 
which  can  never  be  learned  from  text-books  or  lectures,  that  it  is 
impossible  to  formulate  rules  for  feeding  which  shall  cover  all  cases; 
but  the  following  suggestions  will  be  found  applicable  in  many 
instances. 

Miss  Nightingale  wrote  that  *' to  watch  for  the  opinions  which 
the  patient's  stomach  gives,  rather  than  to  read  '  analyses  of  foods,' 
is  the  business  of  all  those  who  have  to  settle  what  the  patient  is  to 
eat — perhaps  the  most  important  thing  to  be  provided  for  him  after 
the  air  he  is  to  breathe." 

The  Appetite. — In  judging  of  the  patient's  appetite  it  must  be 
remembered  that  what  is  supposed  to  be  a  lack  of  desire  for  food  is 
possibly  due  merely  to  defective  cooking,  to  serving  meals  at  inop- 
portune moments,  or  to  selecting  food  which  is  not  to  his  liking. 
There  may  be  appetite  enough  for  food,  but  not  for  the  particular 
food  offered,  and  it  is  the  province  of  the  nurse  to  differentiate  such 
matters.  She  should  not  only  save  the  patient  from  physical  exer- 
tion, but  from  the  effort  of  thinking  as  well. 

It  is  the  function  of  the  nurse  to  observe  and  record  all  the  con- 
ditions of  the  patient's  appetite,  digestion,  and  likes  and  dislikes  for 
different  foods,  and  when  her  instructions  have  not  been  specific,  or 
have  not  provided  for  emergencies,  she  should  make  it  a  point  to 
have  them  understood  at  the  next  visit  of  the  physician.  A  thorough 
practical  knowledge  of  dietetics  should  be  the  foundation  of  the  nurse's 
education,  and  this  subject  should  receive  much  more  attention  in 
the  curriculum  of  training  schools  than  is  at  present  bestowed  upon  it. 

The  nurse  has  a  far  better  opportunity  than  the  physician  to 
judge  of  the  patient's  appetite  and  study  his  whims  and  fancies  in 

869 


370  ADMINISTRATION   OF   FOOD   FOR  THE   SICK. 

regard  to  food,  and  she  should  not  fail  to  report  them  and  under- 
stand very  positively  from  the  physician  in  charge  to  what  extent 
she  is  to  be  permitted  to  humour  them  and  substitute  one  form  of 
food  or  drink  for  another.  Directions  are  apt  to  be  given  too  ia- 
definitely  to  the  nurse,  and  with  the  best  intentions,  from  lack  of 
instruction,  she  may  neutralise  the  effects  of  medicines  by  overfeed- 
ing, or  by  irregularities  in  feeding  which  disorder  digestion  and  in- 
terfere with  the  action  of  drugs,  besides  making  the  patient  worse. 
She  is  often  merely  told  to  give  "  soft  diet "  or  "  fluid  food,"  and  she 
promptly  resorts  to  milk  and  eggs,  which  may  or  may  not  agree 
and  nourish.  Or  instead  of  such  vague  orders  she  may  be  directed 
to  give  only  some  one  form  of  food,  which  she  conscientiously  does, 
offering  it  in  spite  of  the  patient's  accumulating  nausea  and  disgust, 
with  the  result  of  half  starving  him,  because  the  physician  has  for- 
gotten to  allow  the  nurse  any  latitude  or  discretion. 

Regularity  in  Feeding. — The  hospital  nurse  should  be  taught 
that  it  is  as  important  to  give  food  as  medicines  at  regularly  appointed 
intervals.  Punctuality  should  be  carefully  observed  in  serving  all 
meals  to  the  sick.  There  is  much  unconscious  habit  in  regard  to 
eating,  and  an  appetite  which  was  ready  at  the  accustomed  hour  of 
receiving  food  may  vanish  if  the  meal  is  delayed.  It  is  well,  when 
possible,  to  bathe  the  patient's  face  and  hands  before  offering  a 
meal.  It  is  best  always  for  the  same  nurse  to  have  the  charge 
of  feeding  a  definite  number  of  patients.  If  they  are  served  by  a 
different  nurse  at  each  meal  it  is  much  more  difficult  to  report  those 
whose  appetites  are  defective  or  capricious. 

Quantity  of  Food. — Among  the  first  considerations  is  the  proper 
quantity  of  food  to  offer  the  sick,  and  the  extent  of  its  dilution. 
Miss  Nightingale  has  said  that  "  an  almost  universal  error  among 
nurses  is  the  bulk  of  the  food,  and  especially  of  the  drinks,  they  offer 
to  their  patients,"  and  "  it  requires  very  nice  observation  and  care 
(and  meets  with  hardly  any)  to  determine  what  will  not  be  too  thick 
or  strong  for  the  patient  to  take,  while  giving  him  no  more  than  the 
bulk  that  he  is  able  to  swallow." 

By  diluting  milk,  stimulants,  and  gruels  too  much,  or  making  beef 
tea  too  weak,  the  quantity  of  the  fluid  is  so  great  that  the  patient 
soon  tires  of  swallowing,  and  stops  before  enough  nourishment  has 
been  obtained.  Predigested  milk  possesses  the  decided  advantage 
that  it  aids  the  assimilation  of  the  milk  without  adding  to  its  bulk,  as 
lime  water  and  other  substances  do. 

When  the  appetite  flags  it  is  unwise  to  ask  the  patient  each  time 
beforehand  what  he  would  like  to  eat.  It  is  often  the  unexpected 
which  pleases.  The  smell  of  cooking  and  the  noise  of  the  prepara- 
tion of  food  should  be  kept  from  the  sick-room.  The  nurse  should 
never  eat  her  own  meals  in  the  presence  of  the  patienc. 


METHODS    OF   FEEDING   THE   SICK. 


371 


Details  of  serving  Food. — Hot  food  should  be  served  very  hot 
and  cold  articles  very  cold,  for  lukewarm  food  is  unpalatable. 
In  serving  hot  beverages  or  foods  the  cups  or  plates  should  be  first 
well  heated.  Milk  and  butter  should  be  kept  cold  and  well  covered. 
A  simple  refrigerator  is  easily  improvised  by  placing  a  few  large 
lumps  of  ice  in  a  dish  pan  or  pail  kept  by  an  open  shaded  window, 
and  wrapping  them  in  flannel  to  prevent  evaporation. 

Patients  may  appear  too  ill  to  notice  details,  whereas  they  are  often 
only  too  ill  to  speak  of  them,  and  a  refined,  fastidious,  or  nervous 
patient  may  have  the  appetite  wholly  destroyed  by  the  carelessness 
of  a  nurse  who  tastes  the  food  in  the  patient's  presence  or  with  his 
spoon,  or  who  serves  food  with  unclean  hands.  Untasted  food, 
dishes  after  use,  or  half-emptied  cups  or  glasses  should  never 
be  left  standing  about  the  sick-room.  Nothing  is  more  uninviting 
than  to  have  to  drink  from  a  glass  to  the  sides  of  which  stale  milk 
is  adhering.  If  there  is  any  suspicion  of  the  absolute  freshness  of 
milk,  eggs,  butter,  or  fish,  they  should  never  be  served. 

It  is  equally  important  to  make  all  food  look  inviting  by  offering 
it  with  the  most  attractive  china  which  the  house  affords,  and 
with  only  the  cleanest  of  linen.  Dishes  should  always  be  wiped  dry 
on  the  outside,  and  pains  should  be  exercised  not  to  spill  the  con- 
tents of  cups  into  their  saucers. 

These  may  appear  trivial  details,  but  it  must  be  remembered  that 
the  horizon  of  the  sick-room  is  very  limited,  and  a  patient  who  has 
been  long  confined  to  bed  with  a  serious  illness  thinks  a  great 
deal  of  his  immediate  surroundings.  The  taking  of  food  is  the 
chief  event  of  the  day  for  him,  and  too  much  care  cannot  be  be- 
stowed upon  the  minutiae  of  service,  while  the  natural  stimulants  to 
appetite — such  as  fresh  air,  exercise,  and  enlivening  companionship 
are  necessarily  wanting. 

When  patients  are  able  to  partially  sit  up  for  their  meals,  the 
nurse  should  see  that  they  have  a  comfortable  position  in  the  bed, 
and  that  the  food  tray  does  not  cramp  the  arms  or  legs.  The 
effort  of  sitting  up  may  cause  fatigue  too  soon  and  destroy  the 
appetite  before  the  meal  is  half  done. 

As  a  rule,  twice-cooked  food  should  not  be  served  to  invalids. 
This  applies  especially  to  meat,  fish,  and  vegetables.  Whenever 
economy  is  an  important  consideration,  it  is  better  to  cook  but  little 
food  at  a  time,  and  serve  it  fresh  and  hot.  Food  is  often  made 
unpalatable  by  being  too  greasy,  and  this  is  one  of  the  chief  objec- 
tions to  the  use  of  meat  broths,  and  mutton  or  chicken  broth  should 
always  be  several  times  skimmed  before  they  are  given,  and  blotting 
paper  or  a  bit  of  bread  can  be  passed  over  the  surface  to  remove 
the  last  trace  of  oily  substance.  A  chafing  dish  is  invaluable  for  the 
convalescent  from  protracted  illness. 


372 


ADMINISTRATION   OF   FOOD  FOR   THE   SICK. 


When  the  dietary  ordered  is  very  limited  in  variety,  the  patient  is 
often  gratified  by  having  his  food  served  in  "courses,"  and  will  eat 
more  than  if  given  everything  at  once. 

In  other  cases,  when  a  patient  is  first  allowed  to  sit  up  for  half 
an  hour  or  more  beside  the  bed,  it  may  be  well  to  utilise  this  time 
for  giving  the  principal  meal  of  the  day,  which  will  be  eaten  with 
more  relish,  and  perhaps  better  digested  in  consequence. 

Patients  having  nausea  or  other  gastric  disorder  or  diarrhoea 
should  be  given  but  little  food  at  once.  Small,  oft-repeated  feed- 
ings are  best  for  them.  As  a  rule,  invalids  need  more  salt,  but  less 
sugar,  than  those  in  health. 

When  patients  are  being  fed  with  fluids,  wholly  different  recep- 
tacles should  be  used  for  holding  their  medicines,  or  the  association 
of  ideas  may  be  strong  enough  to  destroy  what  little  appetite  there 
is,  and  even  to  produce  nausea. 

The  nurse  should  always  have  a  cheerful  manner  and  a  cleanly  and 
tidy  appearance,  which  contribute  much  towards  the  patient's  appe- 
tite. She  should  never  offer  nourishment  too  soon  after  removing 
the  vessels  employed  for  the  patient's  discharges  or  evacuations,  but 
should  allow  a  proper  interval  to  elapse,  and  let  it  be  evident  that 
she  has  thoroughly  cleansed  her  hands.  No  form  of  perfumery 
should  ever  be  used  by  the  nurse.  Bread  crumbs  should  never  be 
allowed  to  fall  into  the  bed,  especially  of  a  helpless  patient. 

When  possible,  it  is  well  to  divert  the  patient's  mind  from  his 
ailments  while  feeding  him  by  introducing  some  cheerful  or  inter- 
esting topic. 

Feeding  Helpless  Patients. — In  feeding  helpless  patients 
with  fluids,  if  the  head  is  to  be  raised,  it  should  be  done  by  placing 
the  hand  beneath  the  pillow  and  raising  both  together  gently.  This 
affords  much  better  support,  and  is  more  comfortable  for  the 
patient,  for  the  head  is  less  likely  to  be  bent  so  far  forward  as 
to  interfere  with  swallowing.  If  a  tumbler  is  used,  it  should 
always  be  small  and  not  more  than  two  thirds  filled.  An  aver- 
age breakfast  cup  holds  eight  fluid  ounces,  and  an  average  tea- 
cup six  fluid  ounces.  A  thirsty  patient  derives  more  satisfaction 
from  draining  a  small  glass  than  from  sipping  from  a  large  one 
which  he  is  not  allowed  to  empty.  The  feeble  patient  should  not 
be  allowed  to  swallow  during  inspiration,  and  the  nurse  should  be 
careful  that  each  mouthful  is  swallowed  before  another  is  given,  to 
prevent  serious  coughing. 

When  a  glass  tube  is  used  for  feeding,  it  should  have  a  flattened 
end  to  hold  in  the  mouth,  and  should  be  bent  near  the  centre  at  a 
slight  angle,  so  that  it  is  unnecessary  to  flex  the  patient's  head.  If 
feeding-cups  with  spouts  are  employed,  they  should  be  of  glass,  so 
that  the  nurse  can  see  how  much  the  patient  is  taking ;  otherwise 


METHODS   OF   FEEDING  THE   SICK.  373 

fluid  is  apt  to  be  poured  into  the  mouth  in  too  large  a  quantity.  As 
a  rule,  the  bent  tube  is  decidedly  better  to  use  when  the  patient  has 
any  power  of  suction  at  all.  Even  when  he  has  not,  the  glass  may 
be  raised  by  the  nurse,  so  that  the  fluid  flows  into  the  mouth  with- 
out effort.  The  cup  and  tube  should  always  be  prevented  from 
dripping. 

Sleep  and  Feeding. — Patients  need  only  be  aroused  from  sleep 
to  take  nourishment  in  serious  cases.  Usually  the  ease  with  which 
a  patient  drops  asleep  should  determine  the  necessity  for  awakening 
him.  Sleep  is  often  more  beneficial  even  than  food,  but  there  are 
cases  in  which  a  patient  awakens  to  take  a  sip  of  milk  or  a  few 
mouthfuls  of  food,  and  will  immediately  drop  off  to  sleep  again. 
Such  patients  may  be  aroused  for  food  every  two  hours  if  there  is 
need,  as  there  may  be  in  typhoid  fever.  Some  patients  are  annoyed 
by  awakening  at  three  or  four  o'clock  in  the  morning,  not  being  able 
to  sleep  again.  Food  of  some  sort  should  always  be  kept  on  hand 
during  the  night,  and  drinking  a  cup  of  hot  bouillon  or  cocoa  will 
often  enable  them  to  fall  asleep  again  for  two  or  three  hours. 

Cleansing  the  Mouth. — The  patient's  comfort  is  very  depend- 
ent upon  keeping  a  clean  mouth,  as  indeed  are  his  appetite  and 
taste.  A  helpless  patient  whose  mouth  and  lips  are  allowed  to  be- 
come parched  and  sour  will  refuse  nourishment  which  he  might 
otherwise  gladly  take.  The  mouth  should  be  rinsed  each  time  after 
eating  with  pure  water,  or  diluted  Listerine  (two  teaspoonfuls  to  the 
tumbler  of  water),  or  borax  water  of  similar  strength.  It  is  much 
easier  to  keep  the  mouth  clean  in  this  manner  than  to  disinfect  it 
after  it  has  been  neglected.  Milk  especially  lingers  on  the  mucous 
surface,  and,  fermenting  there,  destroys  the  sense  of  taste  and  de- 
velops germs  that  interfere  with  digestion.  When  the  patient  can- 
not rinse  his  own  mouth,  it  must  be  frequently  cleansed  by  the 
nurse  with  a  swab  of  fresh  cotton  fastened  on  a  small  flexible  stick, 
such  as  a  piece  of  splint,  and  moistened  with  the  mouth  wash.  The 
best  tongue  scraper  is  made  with  a  piece  of  whalebone,  about  nine 
inches  long,  bent  into  a  loop.  If  this  be  applied  before  the  patient's 
meals,  the  taste  nerves  of  the  tongue  will  be  uncovered  from  the 
accumulated  debris  which  coats  them,  and  the  appetite  will  be  im- 
proved. Dry  lips  should  be  moistened  with  vaseline  or  cold  cream, 
not  glycerin. 

Cracked  ice  will  keep  much  longer  if  not  allowed  to  float  in  melt- 
ing water.  The  contact  of  a  metal  spoon  or  dish  also  melts  it  sooner, 
by  virtue  of  the  great  conductivity  of  metal. 

A  piece  of  cheese  cloth,  mosquito  netting,  or  linen  may  be  tied 
over  a  cup  by  an  elastic  band,  and  the  fragments  of  ice  split  off  with 
a  pin  may  be  laid  upon  the  cloth,  so  that  the  melted  fluid  drains  away 
beneath. 


374  ADMINISTRATION  OF   FOOD   FOR   THE   SICK. 

Disinfection  of  Utensils. — All  dishes  or  utensils  used  in  serv- 
ing food  to  patients  having  syphilis,  stomatitis,  or  diphtheria,  or  any 
infectious  disease  likely  to  be  communicated  through  such  means, 
should  be  boiled  for  at  least  an  hour  in  water  containing  a  few  tea- 
spoonfuls  of  soda.  Syphilitic  patients,  especially,  should  have  their 
own  set  of  food  receptacles,  spoons,  forks,  etc.,  properly  labelled,  to 
prevent  any  one  else  from  using  them. 

Feeding  Unconscious  Patients.— The  feeding  of  unconscious 
patients  demands  special  care  and  skill.  They  should  never  be  given 
anything  but  fluid  nourishment,  and  this  must  be  fed  with  a  spoon  or 
through  a  catheter.  Sometimes,  if  the  jaw  is  set,  a  medicine  dropper 
may  be  utilised.  Not  over  a  teaspoonful  should  be  given  at  once, 
and  the  nurse  must  make  sure  that  it  is  swallowed  before  she  repeats 
the  experiment.  It  should  be  remembered  that  the  mechanism  of 
deglutition  is  not  excited  by  one  or  two  drops  of  fluid,  but  usually  at 
least  half  a  drachm  is  required  to  start  this  reflex.  In  feeding  coma- 
tose infants  or  children  with  tubercular  meningitis,  apoplexy,  etc., 
Fernete  and  Widerhofer  advise  pouring  fluids  into  the  nostril  with  a 
spoon  rather  than  into  the  mouth.  It  disturbs  the  child  less  than 
does  the  effort  to  force  open  the  mouth,  and  if  the  head  is  lying  back 
the  fluid  trickles  down  the  posterior  pharyngeal  wall.  Any  excess  of 
fluid  is  returned  through  the  other  nostril.  There  is  no  greater  dan- 
ger of  choking  when  fed  by  this  method  than  by  the  mouth.  It  is 
usually  better,  however,  to  use  a  soft  catheter  with  a  funnel  attached 
to  the  free  end.  The  catheter  is  oiled  or  dipped  in  vaseline  or  butter, 
and  passed  gently  through  the  nostril  down  into  the  oesophagus,  or, 
if  desired,  into  the  stomach.  Before  pouring  any  fluid  into  it  through 
the  funnel  it  must  be  made  certain  that  the  patient  is  breathing 
easily,  and  that  the  tube  has  not  made  a  false  passage  into  the  larynx. 
Such  an  accident  is  very  rare.  This  topic  will  receive  further  atten- 
tion in  connection  with  Lavage. 

Gavage,  or  feeding  with  the  stomach  tube,  is  described  under  that 
heading.  Nasal  feeding  is  employed  sometimes  for  gavage  in  young 
infants,  in  feeding  children  with  diphtheria,  or  the  insane,  who  may 
refuse  food  or  resist  the  passage  of  a  tube  through  the  mouth  by 
biting,  and  it  may  be  used  when  the  mouth  is  sore  from  ulceration  or 
the  effect  of  corrosive  poisons.  The  process  is  described  in  connec- 
tion with  Gavage. 

When  patients  are  living  upon  "teacup  diet,"  or  broths  and 
gruels,  it  is  a  common  mistake  to  give  them  a  diet  which  is  either  too 
low  in  carbohydrates  or  deficient  in  proteid.  The  proper  proportions 
to  be  prescribed,  unless  there  is  some  special  indication  for  the  con- 
trary, will  be  appreciated  by  a  comparison  of  the  following  table, 
compiled  by  Mrs.  E.  H.  Richards,  and  those  previously  given  on 
page  265. 


METHODS  OF   FEEDING  THE   SICK. 


375 


A  Common  Invalid  Ration  too  Low  in  Carbohydrates  (Mrs.  Richards). 


I  pint  of  beef  juice,  containing  7  per  cent . . 
I  pint  of  whole  milk 

1  quart  of  flour  gruel  made  with  whole  milk 

2  quarts  of  liquid.     Total 


Proteid. 


Grammes. 

31-5 
17.0 

18.2 


66.7 


Fat. 


18.0 
18.2 


36.2 


Carbo- 
hydrates. 


Gramtnes. 

22 

38 


60 


Calories. 


129.0 
325-5 
397-9 


852.4 


Nutrient  Enemata. 

Rectal  Absorption. — That  all  mucous  membranes  are  capable 
of  absorbing  certain  materials  from  their  surfaces  and  passing  them 
into  the  blood  vessels  or  lymphatics  has  long  been  recognised  ;  but 
it  is  only  of  comparatively  recent  years  that  this  knowledge  has  been 
applied  extensively  to  the  purpose  of  nourishing  patients  by  means 
of  the  rectum,  and  the  fact  is  now  established  that  sufficient  aliment 
may  be  absorbed  from  the  mucous  membrane  of  the  rectum  or  sig- 
moid flexure  alone  to  sustain  life  for  a  considerable  period,  amount- 
ing in  some  cases  to  from  four  to  seven  weeks.  Moreover,  the  rectum 
may  be  utilised  for  accessory  feeding  for  many  cases  in  which  the 
stomach  is  able  to  digest  some  food,  but  not  in  sufficient  quantity 
to  prevent  emaciation. 

Whenever  rectal  food  enemata  are  employed  certain  principles 
should  be  observed : 

1.  The  rectal  surface  must  be  cleansed  from  all  mucus  and  faeces. 

2.  The  irritation  of  the  rectum  should  be  allayed  as  far  as  pos- 
sible. 

3.  The  quantity  and  quality  of  food  thus  administered  should  be 
so  regulated  as  to  avoid  exciting  peristalsis,  and  yet  allow  of  the 
complete  absorption  of  one  injection  before  another  is  given. 

The  minutest  details  which  will  secure  the  best  conditions  for 
absorption  should  never  be  regarded  as  too  insignificant.  Some 
patients  find  the  idea  of  rectal  feeding  very  repulsive,  and  dislike  to 
submit  to  it ;  but  with  a  little  tact  and  perseverance  their  objections 
can  usually  be  overcome. 

conditions  necessitating  rectal  feeding. 

The  conditions  which  may  require  the  use  of  rectal  feeding  are 
these : 

I.  Temporary  obstruction  to  the  entrance  of  food  into  the  ali- 
mentary canal.  Rectal  feeding  must  be  resorted  to  until  the  ob- 
struction— such  as  the  presence  of  new  growths  and  foreign  bodies, 
or  inflammatory  conditions  with  swelling  in  the  mouth,  pharynx,  or 
oesophagus — can  be  overcome. 


376 


ADMINISTRATION   OF   FOOD   FOR  THE   SICK. 


II.  Inability  to  swallow  food  from  coma,  delirium,  or  paralysis 
affecting  the  mechanism  of  deglutition,  as,  for  example,  post-diphthe- 
ritic paralysis. 

III.  Extreme  irritability,  pain,  acute  inflammation  or  ulceration 
of  the  upper  portion  of  the  alimentary  canal,  such  as  that  excited  by 
corrosive  poisons  like  carbolic  acid,  ammonia,  etc. 

IV.  Stricture  occurring  in  any  part  of  the  alimentary  canal  above 
the  rectum.  . 

V.  Prolonged  reflex  vomiting,  such  as  may  occur  in  pregnancy 
and  seasickness. 

VI.  Gastric  ulcer,  for  the  purpose  of  resting  the  ulcerated  surface 
and  allowing  it  to  heal. 

VII.  Cancer  of  the  stomach  with  inability  to  absorb  or  digest 
sufficient  food,  especially  with  obstruction  to  either  the  cardiac  or 
pyloric  end  of  the  organ. 

VIII.  Any  form  of  severe  gastric  irritation,  such  as  occurs  in 
acute  gastritis. 

IX.  Exhausted  conditions  of  the  system  which  may  be  present 
during  the  course  of  severe  fevers  in  which  absorption  of  even  pre- 
digested  food  is  largely,  suspended. 

X.  For  the  insane  who  refuse  food  by  the  mouth. 

XI.  To  supplement  the  action  of  a  feeble  stomach,  or  when  for 
any  reason,  such  as  total  lack  of  appetite,  emaciation  is  rapidly  pro- 
gressive. 

Hunger  and  Thirst  during  Rectal  Feeding. — These  symp- 
toms are  not  necessarily  present  after  the  first  day  or  two  of  rectal 
feeding.  In  an  obstinate  case  of  gastric  haemorrhage  in  which  abso- 
lutely nothing — not  even  water — was  given  by  the  mouth  for  more 
than  a  week,  I  questioned  the  patient  in  regard  to  her  sensations  of 
hunger  and  thirst,  and  she  told  me  that  they  were  entirely  relieved 
after  the  first  twenty-four  hours'  use  of  nutrient  enemata.  The  mouth 
and  tongue  were  not  dry,  and  she  did  not  lose  weight  during  this 
period.     I  have  been  told  the  same  thing  by  other  patients. 

An  interesting  case  was  reported  by  C.  W.  Brown,  of  Washing- 
ton (Food,  vol.  iv.  No.  8,  1894,  p.  337),  in  which  a  patient  suffering 
from  carcinoma  with  ulceration  of  the  pyloric  end  of  the  stomach 
was  supported  for  forty-three  days  upon  exclusive  rectal  nourish- 
ment consisting  of  from  four  to  six  ounces  of  beef  tea  and  milk, 
which  were  given  on  an  average  once  in  three  hours,  with  the  occa- 
sional addition  of  laudanum  and  a  little  whisky.  During  an  interval 
of  improvement  which  followed  the  exclusive  use  of  injections,  the 
patient  was  able  to  take  some  food  by  the  stomach,  though  not  enough 
to  satisfy  the  cravings  of  hunger  and  prevent  a  feeling  of  faintness ; 
but  these  symptoms  were  overcome  by  giving  four  nutrient  injec- 
tions day  and  night  in  addition  to  the  milk  taken  by  the  stomach. 


METHODS  OF   FEEDING  THE   SICK. 


377 


Method  of  Injection.— The  common  practice  of  giving  nutrient 
enemata  by  a  Davidson  syringe  with  a  short  hard-rubber  or  steel 
nozzle  is  always  to  be  condemned.  In  the  hands  of  an  unskilful 
nurse,  irritation  and  sometimes  haemorrhages  are  likely  to  be  pro- 
duced in  this  way,  sooner  or  later. 

In  commencing  the  use  of  rectal  alimentation,  especially  in  cases 
which  manifest  much  irritation  of  the  lower  bowel,  it  is  important  to 
employ  a  long,  soft,  flexible  rubber  catheter  or  rectal  tube  which  can 
be  passed  well  up,  for  eight  inches  or  more,  to  the  sigmoid  flexure. 
In  selecting  the  tube,  one  should  be  chosen  which  is  not  so  flexible 
that  it  is  liable  to  bend  or  double  upon  itself,  but  which  is  not  so 
stiff  as  to  give  pain  or  damage  the  mucous  membrane  if  it  happens 
to  catch  in  a  fold  of  its  surface.  For  children  a  No.  12  or  No.  14 
ordinary  "  velvet-eyed  "  flexible  catheter  may  be  used,  and  passed 
up  as  high  as  the  sigmoid  flexure.  For  adults  the  tube  should  be  of 
moderate  calibre,  not  exceeding  the  diameter  of  a  stout  pen  handle. 
The  tube  or  catheter  should  be  dipped  in  sweet  oil,  melted  butter,  or 
vaseline;  but  glycerin  must  not  be  used,  for  it  excites  peristalsis. 

In  adults  the  tube  should  be  passed  in  for  from  ten  to  twelve 
inches,  for  the  injection  should  be  plaqed  as  high  up  as  possible. 
When  this  is  done  there  is  less  liability  to  its  rejection,  and  it  is 
brought  in  contact  with  an  extensive  mucous  surface.  There  is  a 
further  physiological  or  anatomical  reason  for  placing  the  injection 
as  high  up  as  may  be,  in  the  fact  that  the  sigmoid  veins  and  those 
returning  the  blood  from  the  upper  rectum  communicate  with  the 
inferior  mesenteric  vein,  while  those  from  the  lower  third  of  the 
rectum  communicate  with  the  inferior  vena  cava.  Consequently, 
whatever  is  absorbed  by  the  wall  of  the  inferior  third  of  the  rectum 
passes  into  the  inferior  vena  cava  without  going  to  the  liver,  but 
that  which  is  absorbed  higher  up  is  returned  to  veins  whose  contents 
reach  the  liver  directly  through  branches  of  the  vena  porta.  It  is 
in  the  liver  that  the  further  digestion  and  assimilation  of  proteid 
material  takes  place  in  great  part,  and  hence  the  desirability  of  ob- 
serving this  rule  for  injection. 

It  was  found  by  Brown,  in  the  case  above  cited  (page  376),  that 
the  patient  was  able  to  discriminate  between  the  taste  of  iodide  of 
potassium  and  ergot,  etc.,  in  from  a  quarter  to  half  an  hour  after 
these  medicines  had  been  given /^r  rectum.  The  same  phenomenon 
has  been  noticed  from  the  injection  of  such  substances  directly  into 
the  stomach  through  a  gastric  fistula,  and  it  is  due  to  their  ready 
absorption  and  conveyance  in  the  blood  to  the  taste  bulbs  in  the 
tongue  or  to  the  saliva,  in  which  fluid  the  iodide  of  potassium  is 
promptly  excreted. 

According  to  some  observers,  under  the  best  conditions  not  over 
one  fourth  of  the  necessary  nutriment  can  be  absorbed  from  the 


378 


ADMINISTRATION   OF   FOOD  FOR   THE   SICK. 


rectum  (Bauer).  Such  a  statement  should  be  considerably  modified, 
for,  as  a  matter  of  practical  experience,  many  patients  may  be  kept 
alive  and  gain  slightly  in  weight  upon  the  use  of  nutrient  enemata, 
when  they  are  intelligently  given.  If  injected  but  a  short  distance 
into  the  intestine,  the  absorbing  surface  is  so  limited  that  compara- 
tively little  material  is  taken  up  ;  but  if  given  in  the  manner  pre- 
scribed above,  through  a  long  catheter  inserted  high  up,  much  more 
will  be  retained,  and  the  benefit  derived  from  such  injections  will  be 
enhanced. 

The  injection  should  be  applied  by  means  of  a  small  hard-rub- 
ber syringe,  which  need  not  hold  over  two  ounces.  Very  little  force 
should  be  used,  and  the  patient  must  be  told  not  to  strain.  After 
the  syringe  is  filled,  by  holding  it  vertically  nozzle  uppermost  and 
pressing  it  until  the  fluid  exudes  from  the  nozzle,  all  air  is  excluded. 
When  a  Davidson  syringe  is  used  for  the  purpose  of  injecting  small 
quantities  of  fluid,  it  very  often  happens  that  air  is  drawn  into  the 
syringe  in  addition  to  the  materials  of  the  enema,  which,  when  in- 
jected, is  very  apt  to  excite  peristalsis  and  evacuate  the  bowel.  The 
use  in  unskilful  hands  of  a  funnel  or  fountain  syringe  for  filling 
the  tube  is  open  to  the  same  objection — that  air  is  likely  to  enter 
the  rectum.  In  any  case  it  is  well  to  fill  the  tube  with  the  injection 
fluid  before  it  is  inserted. 

When  the  enemata  are  given  in  gynaecological  or  obstetric  cases, 
it  should  be  remembered  that  tight  tamponing  of  the  vagina  may 
interfere  with  absorption  from  the  rectum. 

Aids  to  Retention. — Upon  withdrawing  the  tube,  if  there  is 
danger  that  the  injection  will  not  be  retained,  a  soft  compress  or 
folded  towel  should  be  pressed  up  firmly  against  the  anus  for  twenty 
minutes  or  half  an  hour. 

The  retention  of  the  enema  is  aided  by  placing  the  patient  in  a 
proper  position.  He  should  lie,  if  possible,  upon  the  left  side,  with 
the  hips  raised  high  upon  a  pillow,  and  the  injection  should  be  given 
very  slowly  and  carefully.  The  "Sims"  gynaecological  position  is 
the  best,  but  with  the  hips  more  elevated. 

Temperature  of  Injections.— All  food  enemata  should  be 
given  moderately  warm,  at  a  temperature  of  90°  or  95°  F.  They  are 
less  apt  to  excite  peristalsis  than  if  administered  very  hot  or  very 
cold. 

Number  of  Injections. — The  question  of  how  many  injections 
can  be  given  must  depend  upon  the  irritability  of  the  rectum.  It 
can  never  be  used  like  the  stomach,  and  it  is  advisable  to  begin  by 
ordering  an  enema  only  once  in  six  hours.  If  the  rectum  is  in  good 
condition  the  number  may  be  increased  to  one  every  four,  or  even 
every  three  hours.  In  exceptional  cases  or  for  emergencies  small 
injections,  not  exceeding  one  and  a  half  ounce,  may  be  given  once 


METHODS  OF  FEEDING  THE   SICK,  379 

in  two  hours ;  but  if  repeated  at  such  brieiifmervals,  they  are  almost 
certain  to  excite  irritation. 

CARE   OF   THE   RECTUM. 

When  it  is  important  that  nutrient  enemata  should  be  continued 
for  some  time,  the  exact  condition  of  the  rectum  should  be  ascer- 
tained by  the  physician,  and  the  most  minute  directions  should  be 
given  to  the  nurse.  The  matter  is  not  infrequently  left  to  an  attend- 
ant, who  is  wholly  ignorant  of  the  proper  conditions  to  be  observed, 
and  failure  is  sometimes  reported  when  a  little  intelligent  attention 
bestowed  upon  details  would  overcome  all  difficulties. 

As  already  stated,  many  cases  have  been  recorded  in  which 
patients  have  been  nourished  exclusively  by  nutrient  enemata  for 
several  weeks,  and  it  is  an  important  fact  that  the  rectum  may 
acquire  a  certain  degree  of  toleration  for  them.  For  the  first  few 
days  they  may  be  rejected,  but  when  correctly  prepared  and  adminis- 
tered they  will  soon  be  successfully  retained.  But  it  is  only  in  the 
most  favourable  cases  that  rectal  alimentation  can  be  long  continued 
without  eventually  producing  irritation  and  diarrhoea,  and  in  the 
majority  of  instances  this  is  likely  to  occur  after  two  or  three  weeks. 
The  enemata  must  then  be  discontinued,  but  may,  if  necessary,  be 
resumed  again  after  a  brief  interval. 

The  presence  of  haemorrhoids  is  a  serious  drawback  when  the  use 
of  rectal  feeding  becomes  imperative,  and  care  should  be  exercised 
not  to  irritate  or  inflame  them  by  the  passage  of  the  catheter  or 
nozzle  of  the  syringe.  In  such  cases  it  is  necessary  to  use  only  a 
very  soft  and  flexible  catheter,  and  to  allay  irritation  by  the  topical 
application  of  a  2-per-cent  solution  of  cocaine. 

Whenever  nutrient  enemata  are  employed  for  a  long  time  the 
rectum  should  be  thoroughly  evacuated  and  cleansed,  at  least  once 
a  day,  by  flushing  with  a  copious  injection  of  warm  soapsuds  and 
water,  amounting  to  two  or  three  pints,  immediately  after  which  a 
food  enema  should  be  given. 

The  cleansing  enemata  may  be  given  through  a  double  or  single 
catheter.  If  a  double  catheter  is  preferred,  a  larger  quantity,  two 
or  three  quarts,  of  water  may  be  advantageously  given,  and  a  few 
grains  of  common  salt  should  be  added  to  each  injection.  If  the 
rectum  is  irritable,  and  much  mucus  coats  its  inner  surface,  it  may 
be  well  to  add  boric  acid  to  the  water.  The  injection  washes  out 
any  particles  of  waste  matter  or  remains  of  a  previous  nutrient  in- 
jection, cleanses  the  mucous  surface,  stimulates  its  circulation,  and 
prepares  it  for  better  absorption. 

Opium  in  Enemata. — Opium,  while  it  prevents  peristaltic  ac- 
tion and  favours  retention  of  the  enema,  may  also  tend  to  interfere 
with  its  absorption.     It  is  consequently  to  be  avoided,  if  possible, 


*80  ADMINISTRATION   OF   FOOD   FOR  THE  SICK. 

but  when  irritation  of  the  rectum  exists  it  becomes  necessary  to  in- 
ject a  little  laudanum.  Ordinarily,  three  to  four  minims  is  sufificient, 
but  ten,  or  even  twenty,  may  be  required  in  some  cases.  This  dosage 
must  not  be  often  repeated.  Its  effect,  of  course,  should  be  watched^ 
and  it  must  not  be  given  too  freely.  If  nutrient  enemata  are  con- 
stantly employed  it  is  sometimes  found  that  a  larger  dose  injected 
by  a  small  hard-rubber  syringe  half  an  hour  or  an  hour  before  giv- 
ing an  enema  allays  the  irritation  more  completely  than  if  the 
opium  is  given  in  one  of  its  constituents.  Injected  by  itself,  the 
quantity  of  opium  is  so  small  that  it  does  not  excite  peristalsis,  but 
is  absorbed,  and  its  local  action  is  obtained  before  the  larger  bulk  of 
fluid  in  the  enema  is  injected.  In  other  cases  it  is  sufficient  to  give 
the  laudanum  in  very  small  quantity,  five  or  six  minims  with  each 
enema.  Instead  of  laudanum,  the  deodorised  tincture  of  opium  or 
McMunn's  elixir  may  be  used. 

SUBSTANCES   AVAILABLE   FOR   RECTAL   FEEDING. 

Of  the  different  classes  of  foodstuffs,  there  are  some  which  are 
absorbed  readily  by  the  rectum,  while  others  are  scarcely  taken  up 
at  all.  To  the  latter  class  .belong  starches  and  most  of  the  fats. 
Those  starches  which  are  predigested  and  partially  converted  into 
sugar  may  be  absorbed  to  a  very  limited  extent,  but  not  sufficiently 
to  add  to  the  nutrition  of  the  body.  Maltine  may  sometimes  be  ab- 
sorbed. Fats  and  oils  not  only  remain  unabsorbed  by  the  rectum, 
but  they  prevent  the  absorption  of  other  foods  by  coating  either  the 
mucous  membrane  or  the  food  itself,  and  are  therefore  worse  than 
useless.  Attempts  have  been  made  to  give  them  saponified  or 
finely  emulsified,  prepared  with  pancreatin  or  otherwise,  but  it  is 
doubtful  if  even  under  these  circumstances  enough  of  any  form  of 
fat  or  oil  can  be  taken  up  to  be  of  practical  bene'fit  in  rectal  feeding. 

It  is  exceedingly  important  to  use  -only  materials  which  will  be 
as  completely  absorbed  as  possible.  Anything  else  acts  as  a  foreign 
body,  and  in  time  proves  more  or  less  irritating.  Moreover,  it  is- 
found  that  many  albuminous  materials  which  are  absorbed  from  the 
surface  of  this  portion  of  the  intestine  become  irritating  if  given  in 
too  concentrated  a  form,  such  as  pure  peptone,  and  they  must  be 
diluted  to  two  or  three  times  their  volume  with  water  or  some  bland 
fluid.  Some  forms  of  albumin  are  undoubtedly  absorbed  from  the 
mucous  membrane  of  the  rectum  without  predigestion,  such  as  the 
albumin  expressed  from  chopped  meat  or  egg  albumen,  but  it  is 
much  better  to  at  least  partially  pancreatinise  it. 

Pancreatinised  Meat.— In  preparing  proteid  food  for  absorp- 
tion one  of  the  forms  of  pancreatic  extract  or  pancreatin  may  be 
used.  Extracts  of  pancreas  are  open  to  the  objection  that  they  do 
not  keep  very  long,  and  unless  perfectly  fresh  they  are  apt  to  prove 


METHODS  OF   FEEDING  THE   SICK. 


381 


irritating,  and  glycerin  extracts  cannot  be  used  in  any  quantity  on 
account  of  the  aperient  action  of  the  glycerin  itself.  To  overcome 
these  difficulties,  Leube  suggests  using  the  fresh  pancreas,  which  is 
to  be  added  in  the  proportion  of  one  part  to  three  of  beef.  Both 
the  meat  and  the  pancreatic  gland  should  be  scraped  or  thoroughly 
minced  and  rubbed  into  a  paste  with  a  little  warm  water.  Any  fat 
should  be  carefully  removed.  The  pulp  thus  obtained  is  to  be  injected 
by  means  of  a  suitable  syringe  with  a  rather  wide  nozzle.  The  idea 
of  using  this  combination  is  that  the  digestion,  which  is  begun  out- 
side, is  continued  within  the  rectum,  and  the  products  are  gradually 
absorbed.  Leube  claims  that  this  form  of  nutrient  enema  may  be 
retained  for  ten  or  twelve  hours,  and  that  it  is  very  rarely  irritating. 
He  sometimes  adds  egg  albumen  and  even  fat  to  the  mixture. 

It  has  been  advised  to  inject  hydrochloric  acid  into  the  rectum 
with  beef  solutions  as  well  as  with  milk,  but  this  process  is  too  irri- 
tating, and  all  artificial  digestion  should  be  completed  outside  of 
the  body. 

Blood. — Dried  beef  blood  has  sometimes  been  used  as  a  rectal 
food,  but  there  is  no  evidence  that  it  is  absorbed.  In  those  cases  in 
which  I  have  employed  it  it  has  usually  caked  within  the  rectum 
and  prevented  the  absorption  of  other  materials.  Fresh  defibrinated 
blood  has  also  been  used  for  the  same  purpose — four  ounces  may  be 
given  every  six  hours — but  it  possesses  no  advantage  over  predi- 
gested  milk  or  peptones,  and  is  not  to  be  recommended. 

Milk. — Pancreatinised  milk  in  which  the  process  of  predigestion 
has  not  been  carried  too  far  is,  on  the  whole,  one  of  the  most  satis- 
factory foods  which  can  be  used  by  rectum.  It  should  not  be  rich 
in  cream. 

Eggs. — Egg  albumen  is  also  one  of  the  best  ingredients  of  nutri- 
ent enemata.  It  is  absorbed  unaltered  to  some  extent  through  the 
rectal  mucous  membrane,  but  it  is  better  that  it  should  always  be 
predigested  by  the  use  of  a  peptogenic  or  pancreatinising  power. 
The  whites  of  two  eggs  may  be  added  to  peptonised  milk,  or,  better, 
to  peptone  solution  or  one  of  the  meat  extracts.  Ewald,  who  has 
experimented  extensively  with  rectal  alimentation,  states  that  un- 
peptonised  egg  albumen  is  absorbed  as  promptly  from  the  rectal 
surface  as  commercial  peptone,  while  peptonised  egg  albumen  is 
taken  up  even  better.  The  absorption  of  the  albumen  is  furthered 
by  the  addition  of  a  little  table  salt  to  the  injection— about  fifteen 
grains  to  each  egg — but  this  is  sometimes  irritating  to  the  rectum. 

The  yolk  of  egg  is  not  recommended  for  rectal  use,  for  although 
it  contains  albuminous  material,  so  much  fat  is  mixed  with  it,  which 
is  not  absorbed  excepting  by  the  intestinal  villi  in  the  small  intes- 
tine which  are  expressly  constructed  for  the  purpose,  that  it  is  practi- 
pally  useless. 


382 


ADMINISTRATION  OF  FOOD  FOR  THE   SICK. 


Alcohol. — The  alcohol  used  for  rectal  injection  should  be  in  the 
form  of  good  liquor,  somewhat  diluted.  If  pure  alcohol  is  given,  it 
should  be  diluted  in  three  or  four  parts  of  water,  when  it  becomes 
less  irritating  to  the  mucous  membrane  and  is  more  easily  ab- 
sorbed. Very  often  a  small  injection  of  half  an  ounce  of  whisky 
in  an  ounce  and  a  half  of  water,  or  even  an  injection  of  whisky, 
brandy,  or  sherry  and  water  given  alone,  will  be  retained  and  com- 
pletely absorbed,  when  a  larger  volume  of  fluid  or  other  ingredients 
added  to  the  alcohol  will  not  be  retained,  and  the  whole  enema  will 
pass  out  again.  Rum  may  be  used,  or  brandy,  but,  as  a  rule,  good 
whisky  is  the  most  serviceable.  When  alcohol  is  given  in  connection 
with  other  rectal  foods,  it  may  be  unnecessary  to  dilute  it  with 
water,  but  undiluted  whisky  sometimes  causes  precipitation  in  milk. 
If  added  too  strong  it  coagulates  casein  which  has  not  been  pan- 
creatinised,  and  no  solid  matter,  even  in  the  form  of  a  fine  precipi- 
tate, is  of  much  use  in  the  rectum.  Such  an  injection  simply  acts  as 
an  irritant. 

PRESCRIPTIONS   FOR   FOOD   ENEMATA. 

Pwald  recommends  the  following :  Beat  the  whites  of  two  eggs 
with  a  tablespoonful  of  cold  water,  add  a  teaspoonful  or  two  of 
starch  boiled  in  a  half  teacupful  of  a  20-per-cent  glucose  solution,  a 
wineglassful  of  claret,  and  a  teaspoonful  of  peptone  solution.  Mix 
at  a  temperature  below  the  coagulation  point  of  the  albumen. 

Yeo  prescribes  expressed  meat  juice,  egg  albumen,  and  peptones. 

Leube  prefers  the  mixture  of  scraped  meat  and  fresh  pancreas 
made  into  an  emulsion,  as  prescribed  above  (page  381). 

Roberts  gives  milk  gruel  and  beef  tea,  with  two  teaspoonfuls  of 
liquor  pancreaticus  freshly  mixed.  He  reports  a  case  in  which  he 
sustained  the  patient's  life  for  nine  weeks  upon  this  treatment  alone. 

FOOD  SUPPOSITORIES. 
Rectal  food  suppositories  are  sometimes  made  of  predigested 
and  evaporated  or  condensed  forms  of  milk  or  meat  juice,  which  are 
mixed  with  oil  or  cacao  butter  and  pressed  into  an  elongated  bougie- 
or  suppository.  They  sometimes  prove  useful,  and  are  certainly  con- 
venient, but  they  possess  no  real  advantages  over  nutrient  enemata, 
and  if  the  use  of  rectal  feeding  is  to  be  long  continued,  the  latter 
are  found  more  practical. 


Inunction  Foods. 

Attempts  are  sometimes  made  to  get  nourishment  into  the  body 
by  means  of  inunction  through  the  skin,  and  olive  oil,  cod-liver  oil, 
and  cacao  butter  are  rubbed  into  the  integument  of  the  abdomen 


MEDICINES  AND  FOOD.  383 

and  thighs.  This  means  is  naturally  only  employed  in  cases  of  ex- 
treme emaciation  from  wasting  diseases,  such  as  carcinoma,  maras- 
mus, and  phthisis.  It  has  proved  mainly  useful  with  marasmic 
infants,  but  it  is  doubtful  whether  it  possesses  any  true  value  beyond 
the  advantage  of  lubricating  a  dry  and  shrivelled  skin,  and  retaining 
some  of  the  body  heat  in  case  of  great  feebleness. 

Intravascular  Feeding. 

In  extreme  cases  of  collapse,  where  death  has  seemed  imminent, 
nutrient  injections  have  sometimes  been  given  directly  into  the 
veins.  Of  late  years,  however,  it  has  been  shown  that  in  collapse 
from  haemorrhage,  or  from  loss  of  fluid  in  the  evacuations  of  Asiatic 
cholera  and  cholera  morbus  in  infants,  salt-water  injections  answer 
as  well,  and  have  the  advantage  of  being  much  safer  and  easier  of 
application. 

Hodder  was  the  first  to  practise  the  intravenous  injection  of 
milk  in  1850  for  collapse  from  Asiatic  cholera,  and  T.  G.  Thomas 
was  among  the  first  to  inject  warm  milk  into  one  of  the  veins  of  the 
arm.  He  reported  one  case  in  which  eight  ounces  of  milk  adminis- 
tered in  this  way  saved  life.  Both  goat's  and  cow's  milk  have  been 
so  used,  but  the  milk  must  be  rendered  alkaline. 

Down  reports  similar  success.  Fowler  tried  intravenous  injec- 
tion of  peptone  solution,  and  has  given  as  much  as  six  ounces  of  a 
digested  beef  solution  in  this  manner.  The  peptone  does  not  reap- 
pear in  the  urine,  but  the  casein  of  milk  does,  as  well  as  solutions 
of  sugar  or  albumen  when  injected  into  a  vein.  Some  of  the  oil 
cells  in  milk  have  greater  diameter  than  the  capillaries,  which  might 
prove  a  practical  objection  to  the  injection  of  unskimmed  milk. 

Hypodermic  Feeding. 

Feeding  in  cases  of  desperate  exhaustion  by  hypodermic  injec- 
tions of  milk  and  of  peptone  solutions  has  been  several  times  at- 
tempted, but  the  results,  beyond  the  use  of  alcohol  by  this  method, 
have  not  proved  sufificiently  satisfactory  to  warrant  its  continuance. 

MEDICINES    AND    FOOD. 

Too  little  attention  has  been  bestowed  upon  the  mutual  relations 
of  food  and  medicines.  So  little  is  really  definitely  known  of  the 
intricate  chemistry  of  digestion  and  assimilation  that  it  is  difficult 
to  formulate  rules  for  the  right  time  of  giving  every  drug  in  rela- 
tion to  fulness  or  emptiness  of  the  stomach.  The  reaction  of  the 
stomach  contents  varies  from  alkaline  to  neutral  and  acid,  and  these 
several  reactions  will  decompose  medicines  in  various  ways.  Besides 
27 


384 


ADMINISTRATION   OF   FOOD   FOR   THE   SICK. 


this,  the  reactions  themselves  are  dependent  upon  a  large  number  of 
organic  acids,  salts,  and  other  substances  which  may  wholly  alter  the 
composition  of  a  medicine  at  one  time,  and  not  be  present  to  affect 
it  at  another. 

A  drug  given  after  a  full  meal  may  be  decomposed  by  the  strong 
hydrochloric  acid  of  active  digestion,  which  is  unaltered  in  an  empty 
stomach. 

Conversely,  remedies  which  are  not  themselves  influenced  by  the 
gastric  and  pancreatic  juices  may  affect  these  secretions  as  synergists 
or  the  reverse.  Chittenden  says:  "Take,  for  example,  the  influence 
of  such  substances  as  urethan,  paraldehyde,  and  thallin  sulphate  on 
the  proteolytic  action  of  pepsin-hydrochloric  acid,  and  we  find  that 
small  quantities  (o.i  to  0.3  per  cent)  tend  to  increase  the  rate  of  pro- 
teolysis, while  larger  amounts,  say  one  per  cent,  decidedly  check 
proteolysis.  Similarly,  among  inorganic  compounds,  arsenious  oxide, 
arsenic  oxide,  boric  acid,  and  potassium  bromide  in  small  amounts 
increase  the  proteolytic  power  of  pepsin  in  hydrochloric-acid  solu- 
tion, while  larger  quantities  check  the  action  of  the  ferment  in 
proportion  to  the  amounts  added.  Again,  with  the  enzyme  trypsin, 
similar  results  with  such  salts  as  potassium  cyanide,  sodium  tetra- 
borate, potassium  bromide  and  iodide  may  be  quoted  as  showing  not 
only  the  sensitiveness  of  the  ferment  towards  foreign  substances,  but 
likewise  its  peculiar  behaviour — viz.,  stimulation  in  the  presence  of 
larger  quantities.  Furthermore,  we  have  found  that  even  gases,  as 
carbOnic-acid  and  hydrogen-sulphide,  exert  a  marked  retarding  in- 
fluence on  the  proteid-digesting  power  of  trypsin."  These  gases, 
being  a  product  of  intestinal  malfermentation,  may  thus  interfere 
with  digestion. 

Hydronaphthol  and  bismuth  salicylate  retard  gastric  digestion. 
Sodium  bicarbonate  and  other  alkalies  check  pyrosis  in  chronic  gas- 
tritis, which  is  caused  by  diminished  hydrochloric-acid  secretion,  but 
increase  pyrosis  subsequently,  because  of  the  greater  alkalinity  pro- 
duced, which  favours  the  growth  of  lactic-acid  organisms.  Accord- 
ing to  Leffmann  and  Beam,  beta-naphthol  stops  the  action  of  diastase, 
but  not  that  of  the  amylolytic  ferment  of  pancreatin,  hence  it  is  use- 
ful as  an  intestinal  antiseptic  without  wholly  stopping  digestion.  It, 
however,  retards  proteid  digestion.  They  also  state  that  salicylic 
acid  and  saccharin  both  prevent  the  amylolytic  action  of  diastase  and 
of  pancreatin,  but  do  not  retard  proteid  digestion. 

These  few  examples  are  sufficient  to  illustrate  the  very  diverse 
influence  of  some  of  the  common  drugs. 

The  following  rules  are  subject  to  many  exceptions,  but  they  will 
serve  as  a  general  guide  : 


medicines  and  food.  385 

Rules  for  administering  Medicines  in  Relation  to 

Food. 

1.  Alkalies  are  best  given  shortly  before  meals,  unless  designed 
to  neutralise  hypersecretion  of  hydrochloric  acid. 

2.  Acids  should  be  given  within  half  an  hour  after  meals, 

3.  Bitters  should  be  given  before  meals. 

4.  Remedies  such  as  iron  and  arsenic,  which  may  prove  somewhat 
irritant  to  mucous  membranes,  should  be  given  either  soon  after  the 
regular  meals  or  after  taking  some  simple  article  of  food.  Ammo- 
nium carbonate  and  potassium  iodide,  for  example,  may  be  pre- 
scribed in  milk.     This  also  modifies  their  disagreeable  taste. 

5.  Most  cough  medicines,  cardiac  tonics,  diuretics,  and  systemic 
remedies  which  are  not  especially  irritating  to  the  stomach  should 
be  taken  between  meals.  They  will  be  more  promptly  absorbed  from 
an  empty  stomach,  and  are  less  liable  to  be  altered  in  composition 
by  digestive  fluids  or  to  inhibit  digestion. 

6.  Remedies  designed  to  act  in  the  intestine  and  not  in  the 
stomach,  such  as  salol,  should  be  given  at  the  end  of  gastric  diges- 
tion, when  the  stomach  contents  are  about  to  pass  into  the  intes- 
tine. 

7.  Saline  laxatives  should  always  be  taken  at  least  half  an  hour 
or  an  hour  before  meals,  preferably  before  breakfast ;  but  the  stronger, 
more  slowly  acting  cathartics  should  be  given  on  an  empty  stomach 
at  night. 

Cod-liver  oil  should  be  given  an  hour  and  a  half  after  meals,  or 
on  an  empty  stomach  before  retiring. 

According  to  Whitehead,  starchy  food  should  be  avoided  while 
iodine  preparations  are  being  administered,  because  of  the  insoluble 
compound  likely  to  be  formed  of  iodine  and  starch.  Syphilitics,  he 
says,  should  therefore  eat  meat  and  light  green  vegetables  only,  in 
order  to  get  a  maximum  effect  from  the  remedy.  If  they  are  taking 
very  large  quantities,  such  as  half  an  ounce  or  more  a  day,  this  may 
be  advisable,  but  it  is  unnecessary  for  ordinary  cases. 

Foods  and  beverages  may  be  often  used  to  disguise  the  taste  of 
disagreeable  or  bitter  medicines,  especially  for  children.  An  un- 
pleasant dose  may  often  be  smuggled  down  in  a  teaspoonful  of  jam 
or  a  little  molasses,  and  quinine  is  somewhat  disguised  by  mixture 
in  chocolate  lozenges.  It  may  be  given  in  solution  to  adults  in  cof- 
fee. Castor  oil  is  given  floating  on  coffee  or  beer.  Both  milk  and 
Vichy  partially  disguise  the  taste  of  potassium  iodide. 

Milk  is  an  excellent  vehicle  for  powders,  such  as  bismuth,  mag- 
nesium carbonate,  or  sulphonal.  Many  bitter  medicines  may  be  fol- 
lowed by  a  lump  of  sugar  or  a  strong  peppermint  lozenge,  or  the 
mouth  may  be  rinsed  with  a  little  brandy  and  water.     Chocolate  is 


386  ADMINISTRATION  OF  FOOD  FOR  THE   SICK. 

also  a  good  vehicle  for  the  administration  of  bitter  medicines,  and  it 
may  be  employed  to  emulsify  cod-liver  oil. 

DIET-KITCHEN    OUTFIT. 

When  a  case  of  protracted  severe  illness  occurs  in  a  household  it 
is  very  convenient  to  improvise  a  small  diet  kitchen  in  a  room  next 
the  patient's  bedroom.  The  outfit  should  consist  of  the  following 
articles,  in  addition  to  the  usual  receptacles  for  containing  the  food : 

A  spirit  or  gas  lamp  kept  ready  to  heat  a  porcelain- lined  sauce- 
pan at  any  time,  day  or  night. 

A  double  porcelain-lined  saucepan  for  a  hot-water  bath. 

A  cooking  thermometer  for  use  in  hot  fluids. 

A  measuring  glass  to  hold  six  or  eight  ounces. 

Pancreatin  powders. 

A  bottle  of  rennet  ferment. 

Sodium  bicarbonate,  two  or  three  ounces. 

Borax,  half  a  pound  (to  clean  utensils). 

A  glass  funnel. 

A  meat-mincing  machine. 

A  good  chafing  dish,  although  not  necessary,  is  highly  desirable. 

TRAINED    PURVEYORS    OF    FOOD. 

The  training  of  food  purveyors  for  hospitals,  asylums,  and  other 
institutions  has  only  quite  lately  received  the  attention  which  it  de- 
serves, and  hospital  managers  are  awakening  to  the  fact  that  it  is 
truly  economical  to  employ  a  skilful  trained  buyer  who  understands 
something  of  food  values,  dietetically  as  well  as  pecuniarily,  and  who 
studies  the  conditions  of  the  market  at  different  seasons  of  the  year 
in  order  to  secure  variety  of  food  at  a  minimum  cost.  To  meet  the 
constantly  increasing  demand  for  such  persons,  the  Pratt  Institute, 
of  Brooklyn,  has  this  year  opened  a  series  of  three-months'  courses 
for  both  men  and  women,  which  are  to  cover  the  following  topics: 
(i)  The  selection  of  food  material  as  to  quality,  food  value,  and 
cost.  Marketing  and  buying  by  sample.  (2)  Methods  of  prepara- 
tion in  a  large  way  and  by  appropriate  apparatus.  The  care  of 
food,  cold  storage,  etc.  (3)  Serving,  embodying  general  dining 
economy,  labour-saving  appliances,  etc.  Field  work,  visits  to  public 
kitchens,  and  manufactories  of  kitchens,  and  hotel  furnishings. 


PART   VIII. 

DIET   IN   DISEASE.— DIET   IN   INFECTIOUS 
DISEASES. 


DIET    IN    FEVER    IN    GENERAL. 

The  general  principles  of  the  dietetic  treatment  of  the  condition 
of  fever  which  accompanies  many  different  diseases  are  conveniently 
studied  collectively,  while  the  special  modifications  of  diet  required 
for  certain  infectious  fevers  will  be  considered  under  their  several 
headings. 

The  cardinal  principles  of  feeding  the  sick  involve,  first,  the  avoid- 
ance of  all  articles  that  disagree  with  the  condition  present,  and  sec- 
ond, the  giving  of  the  food  best  adapted  to  relieve  the  digestive  or- 
gans of  unnecessary  labour  and  to  maintain  nutrition.  In  addition, 
for  certain  special  diseases  there  are  classes  of  foods  which  have  dis- 
tinctly curative  value — for  example,  the  use  of  fresh  fruits  and  vege- 
tables in  scurvy,  fats  and  oils  in  scrofula  and  tuberculosis.  Although 
there  is  no  curative  food  for  fevers,  it  should  be  remembered  that 
there  is  nothing  so  easily  assimilated  as  water,  and  advantage  must 
be  taken  of  this  fact  to  introduce  other  foods  into  the  body  with  it, 
giving  them  therefore  in  fluid  form. 

Pathological  Physiolog^y  of  Fever. — The  former  treatment 
of  fevers  by  starvation  and  depletion,  on  the  theory  that  the  poison 
of  the  disease  was  soonest  conquered  by  withholding  all  food  and 
drink  upon  which  it  might  thrive,  and  starving  out  "a  devouring 
flame  of  inflammation,"  has  long  been  superseded  by  more  scientific 
methods.  This  early  treatment  culminated  in  France  in  the  first 
part  of  this  century,  and  was  first  combated  in  England  by  Graves 
and  his  successful  followers. 

It  is  now  known  that  in  fevers  by  supplying  the  patient  with 
abundant  nitrogenous  food  the  tissues  of  the  body  are  spared  from 
consumption — in  other  words,  that  the  proteid  matter  of  the  food  is 
burned  up  or  oxidised  instead  of  the  proteid  matter  of  the  patient's 
muscles  and  other  structures.  The  animal  food  thus  given  does  not 
add  to  the  substance  of  the  tissues,  but  saves  them  from  wasting  and 
combustion. 

387 


388 


DIET   IN    DISEASE. 


Bauer  believes  that  "the  gravest  possible  injury  to  the  organism 
of  the  fever  patient  may  be  brought  about  by  a  diet  too  rich  in  albu- 
minates," and  to  some  extent  carbohydrates  and  gelatin  may  be  sub- 
stituted for  them,  yet  he  adds  that  while  "an  exclusive  use  of  albu- 
minates is  undesirable.  ...  In  fever  a  larger  relative  proportion  of 
albuminates  is  requisite  than  in  health,  and  so  much  larger  as  the 
albuminous  metabolism  is  greater." 

Fever  patients  commonly  excrete  much  more  nitrogen  than  they 
take  in  as  food.  In  so  doing  it  is  believed  that  they  first  exhaust 
whatever  reserve  supply  may  be  on  hand  in  the  food  proteids  pre- 
viously absorbed  and  circulating  in  the  blood,  and  subsequently 
draw  upon  the  tissues,  just  as  is  the  case  in  starvation.  The  urea 
daily  eliminated  during  fever  may  exceed  by  forty  or  fifty  grammes 
the  normal  amount  voided  in  the  urine  during  health,  and  this  may 
be  the  case  even  when  no  food  is  given  ;  hence  the  waste  increase  is 
mainly  nitrogenous  (Bauer).  In  chronic  fevers  with  remissions,  like 
tuberculosis,  there  is  less  rapid  waste  than  in  the  continuous  forms, 
such  as  typhoid.  If  the  digestion  remains  fairly  good  in  any  fever, 
the  loss  of  body  weight  is  proportionately  checked. 

Voit  suggested  the  theory  that  the  tissues  act  somewhat  after  the 
manner  of  gland  cells,  and  normally  attract  such  albuminous  sub- 
stances as  they  need  without  themselves  undergoing  any  serious 
change,  and  Bauer  believes  that  this  hypothesis  may  be  applied  to 
the  consumption  of  proteids  in  fever,  "  that  under  those  conditions 
which  the  febrile  processes  bring  with  them  the  tissues  yield  up  to 
the  circulation  a  larger  proportion  of  their  own  albumin,  and  that 
an  abnormal  amount  of  materials  for  metabolism  is  thus  presented 
to  the  cells."  The  organs  meanwhile  lose  proteids  faster  than  in 
ordinary  starvation,  but  by  the  same  processes.  A  single  albumi- 
nous meal  adds  more  proteid  to  the  circulation,  which  in  starvation 
would  aid  in  restoring  equilbrium  ;  but  in  fever  it  fails  to  do  so,  and 
the  loss  continues  because  the  inflamed  cells  have  for  the  time  being 
lost  their  power  of  assimilation.     Emaciation  therefore  proceeds. 

Another  theory  which  has  been  strongly  advocated,  but  which, 
on  the  whole,  has  less  to  recommend  it,  is  that  the  inflamed  cells 
consume  and  destroy  proteid  material  from  the  blood  at  a  much 
faster  rate  than  in  health,  and  supplying  a  purely  proteid  diet  does 
not  check  the  waste.  The  entire  question  is  exceedingly  intricate 
and  difficult  of  solution.  The  experiments  which  have  been  made  in 
febrile  metabolism  are  somewhat  contradictory,  and  it  is  undoubtedly 
better  to  be  guided  at  present  by  the  results  of  clinical  experience 
in  feeding  fever  patients  than  by  theoretical  formulae. 

This  subject  is  physiologically  very  closely  related  to  the  paren- 
chymatous and  fatty  degenerations  of  organs  which  attend  many  dis- 
eases, but  it  is  impossible  within  the  practical   limitations  ot  this 


DIET   IN   FEVER   IN   GENERAL. 


389 


work  to  enter  into  this  discussion,  and  the  reader  is  referred  to  a 
very  able  presentation  of  these  theories  in  the  chapter  upon  Con- 
sumption in  Febrile  Disease  by  Bauer  in  his  Dietary  of  the  Sick 
(Handbook  of  General  Therapeutics,  v.  Ziemssen). 

Leyden  and  Frankel  believe  that  in  fever  more  fat  as  well  as 
more  albumin  is  consumed  than  in  health,  but  other  authorities 
think  that  fat  destruction  does  not  keep  even  with  albuminous  waste. 

In  fever  the  secretion  of  hydrochloric  acid  is  diminished  or  sus- 
pended in  the  stomach,  and  its  peristaltic  action  is  so  lessened  that 
the  food  Is  apt  to  remain  longer  than  it  should  and  undergo  mal- 
fermentation,  causing  oppression  or  pain,  nausea,  and  vomiting. 
Absorption  also  is  much  reduced  in  fevers.  The  stomach  may 
wholly  give  out,  and,  as  Roberts  observes,  it  becomes  merely  a  con- 
duit, so  that  the  intestine  must  carry  out  the  work  of  digestion 
unaided. 

Dietetic  Treatment. — The  conditions  to  be  met  in  the  dietetic 
treatment  of  fever  are  as  follows  : 

1.  To  save  tissue  waste  by  supplying  sufficient  nourishment. 

2.  To  give  semisolid  or  fluid  nourishment  in  a  form  which  will 
not  overtax  the  enfeebled  digestive  apparatus  or  leave  a  large 
residue  for  decomposition. 

3.  To  give  abundant  fluid  with  the  object  of  relieving  thirst  and 
to  wash  out  through  the  kidneys  the  waste  matter  produced  by  the 
increased  rate  of  metabolism. 

4.  In  some  cases,  to  give  alcohol  as  a  food  as  well  as  a  stimulant. 
In  all  fevers  presenting  periods  of  remission   it  is  desirable  to 

give  the  greater  portion  of  the  food  while  the  temperature  is  lowest, 
so  that  it  will  be  better  digested  and  absorbed,  for  at  this  time  the 
tissues  appear  to  temporarily  recover  their  assimilative  power  to 
some  extent. 

In  mild  cases,  with  remissions,  if  the  appetite  holds  out,  it  may 
do  no  harm  to  allow  some  little  variety  in  the  diet;  but  if  the  fever 
is  brief  and  the  appetite  fails,  it  is  unnecessary  to  force  the  patient 
to  take  food. 

As  a  rule,  in  fevers  which  are  protracted  or  severe,  nourishment 
should  be  given  in  fluid  form.  To  offer  solid  food  in  serious  fevers 
is  practically  to  place  foreign  bodies  in  the  alimentary  canal  which 
merely  ferment  and  putrefy,  causing  discomfort  with  flatus,  fetor, 
and  diarrhoea.  There  are  some  exceptions  to  this,  notably  the  fever 
of  phthisis,  some  forms  of  protracted  sepsis,  and  ague. 

Milk  being  the  first  and  "  natural  food  "  of  man,  it  would  seem 
most  appropriate  that  it  should  constitute  the  staple  article  of  diet 
in  fevers  in  which  the  digestive  powers  are  temporarily  greatly  en- 
feebled or  wholly  suspended.  The  danger  from  its  continuous  and 
exclusive  ^se  arises  from  its  coagulating  in  lumpy  masses,  which  act 


-QQ  DIET   IN   DISEASE. 

practically  as  solid  food,  but  the  many  means  which  are  at  the 
disposal  of  the  physician  and  nurse  make  it  possible  to  overcome 
this  difficulty  almost  completely,  and  by  processes  of  artificial  diges- 
tion milk  may  be  given  ready  for  absorption,  so  that  nutrition  is 
rendered  quite  independent  of  stomach  and  intestinal  digestion.  In 
the  majority  of  cases,  therefore,  milk  is  altogether  the  best  food. 
The  methods  of  giving  it  have  been  described  in  the  section  upon 
Adaptation  of  Milk  for  the  Sick  (page  62),  and  the  reader  is  also  re- 
ferred to  the  section  upon  the  Treatment  of  Typhoid  Fever  (page  398). 

Next  in  importance  to  milk  in  the  diet  of  fever  are  to  be  men- 
tioned the  various  preparations  of  meat — infusions,  extracts,  juice, 
powder,  broths,  etc.  (page  96).  The  fundamental  idea  of  all  such 
preparations  is  the  solution  of  the  nutritious  myosin  of  the  muscle 
fibres  and  its  separation  from  the  much  less  digestible  sarcolemma 
and  the  connective  tissue  constituting  the  sheaths  of  the  muscle 
fasciculi.  These  preparations  may  be  made  from  tender  veal, 
chicken,  roast  beef,  and  beefsteak.  Clear  soups  or  consommh  are  nu- 
tritious and  mildly  stimulating  in  fevers,  but  if  given  often  or  in 
large  quantities  patients  are  very  apt  to  tire  of  them,  and  they 
may  be  considerably  varied  by  flavouring  with  vegetable  juices 
and  extracts  or  aromatic  herbs,  which  afford  variety,  and  as  a  rule 
do  no  harm,  unless  exhausting  diarrhcea  be  present. 

Buss  gives  the  following  mixture  to  fever  patients :  Peptone,  100  ; 
grape  sugar,  300;  rum  or  Cognac,  200;  water,  600  grammes — the 
quantity  to  be  taken  in  twenty-four  hours  in  addition  to  milk,  yolk 
of  egg,  bouillon,  etc.  If  this  food  is  too  sweet,  tincture  of  gentian 
is  added. 

Purees  may  be  given,  made  by  thickening  clear  soup  with  well- 
cooked  arrowroot,  or  finely  ground  rice,  or  thoroughly  baked  wheat- 
en  flour.  Bauer  recommends  the  use  of  "  fruit  soups,"  which  are 
prepared  by  boiling  fruit,  either  fresh  or  dried,  with  the  addition,  if 
desired,  of  grape  sugar,  lemon  peel,  etc.  The  mass  is  then  com- 
pressed and  strained,  and  the  fluid  obtained  has  an  agreeable  taste 
and  somewhat  laxative  action. 

In  cases  of  moderate  severity  and  shore  duration,  when  the  di- 
gestive organs  are  not  greatly  disturbed,  it  is  not  necessary  to  con- 
fine the  patient  to  fluids,  although  solid  food,  especially  meats, 
should  be  withheld.  Semisolid  food  may  be  given,  such  as  milk 
toast,  cream  toast,  soft-cooked  eggs,  beef  jelly,  or  plain  rice  pudding. 
Thoroughly  boiled  oatmeal  gruel  sustains  strength  while  undergoing 
severe  physical  toil,  and  fever  has  some  resemblance  to  muscular 
effort  in  its  temporary  arrest  of  digestive  activity,  so  that  sometimes 
substances  of  this  class  prove  useful  from  their  supporting  power. 

Many  other  varieties  of  farinaceous  and  other  carbohydrate  foods 
are  suitable  in  febrile  cases  when  carefully  prepared  in  fluid  form. 


DIET   IN   FEVER   IN   GENERAL. 


391 


Patients  often  object  to  these  substances  for  the  reason  that  they 
are  tasteless  and  monotonous,  whereas  if  prepared  with  a  little  care, 
by  giving  proper  attention  to  their  flavouring,  they  may  be  made 
very  palatable.  Thin  gruels  of  rice,  oatmeal,  or  barley,  from  which 
all  solid  matter  has  been  very  carefully  removed  by  straining  through 
a  cheese-cloth  bag,  may  be  salted  and  flavoured  with  any  desirable 
aromatic,  such  as  cinnamon,  clove,  nutmeg,  lemon  or  orange  peel ; 
grape  sugar  may  also  be  added.  Such  gruels  may  be  prescribed 
either  alone  or  combined  with  meat  extracts,  or  beef  tea,  or  beaten 
eggs.  The  addition  of  grape  sugar  has  been  recommended  by  See 
and  others  because  of  its  ready  absorption,  and  from  the  fact  that 
it  is  the  form  of  sugar  which  is  produced  from  the  digestive  fermen- 
tation of  starches,  and  is  to  be  regarded,  therefore,  as  an  easily  as- 
similable carbohydrate  which,  to  some  extent,  may  prevent  tis- 
sue waste  by  furnishing  fuel  to  the  body. 

If  a  patient  be  fed  upon  clear  farinaceous  gruels  alone  during 
fever,  he  cannot  thus  obtain  over  eight  or  ten  grammes  of  proteid 
material  per  diem,  or  one  twelfth  of  the  quantity  required  by  a 
healthy  man  at  rest,  and  obviously  he  will  suffer  within  two  or 
three  days  from  tissue  waste  and  inanition.  Egg  albumen,  meat 
broths,  or  gelatin  must  therefore  be  added,  or  the  soups  must  be 
thickened. 

Eggs  may  be  eaten,  but  they  should  never  be  boiled,  and  in  fact 
they  require  but  little  cooking.  They  may  be  beaten  with  boiling 
water  and  strained  and  dropped  into  consomm^  or  light  broth  or 
gruel.  The  yolk  and  the  white  may  be  used  either  separately  or 
together.  The  yolk  may  be  beaten  with  hot  milk  and  water,  or  with 
hot  tea  sweetened  with  grape  sugar  (Yeo),  or  it  may  be  added  to 
brandy.  The  brandy  mixture  of  the  British  Pharmacopoeia  (mistura 
spiritus  vini  gallic;,  Br.  Ph.),  is  made  as  follows:  The  yolks  of  two 
eggs  with  half  an  ounce  of  refined  sugar  are  beaten  and  added  to 
four  ounces  of  Cognac  and  an  equal  amount  of  cinnamon  water. 
The  brandy  in  this  mixture  may  be  still  further  diluted  or  reduced 
to  advantage.  Some  patients  prefer  to  take  eggs  raw,  while  others 
prefer  to  have  them  very  slightly  cooked  by  immersing  them  in 
water  which  has  been  boiling  thus  cooking  them  very  slowly  at  a 
temperature  not  exceeding  180°  F.  for  ten  or  fifteen  minutes.  Eggs 
prepared  in  this  way  are  uniformly  and  lightly  cooked,  and  the  al- 
bumen is  coagulated  in  a  soft  gelatinous  mass  instead  of  the  hard, 
white,  tough  coagulum  which  is  produced  by  greater  heat  (see 
page  90). 

Cold  meat  jellies  as  well  as  simple  sherry  wine  and  lemon  jellies 
may  occasionally  be  given,  but  gelatin  alone  is  not  particularly  nu- 
tritious, and,  in  proportion  to  the  bulk  occupied  by  this  class  of  foods, 
comparatively  little  benefit  is  derived  from  them. 


.Q2  I>IET   IN   DISEASE. 

Gelatin  given  with  other  foods,  especially  those  of  proteid  com- 
position, is  assimilated  much  better,  and  makes  a  desirable  addi- 
tion to  the  dietary  in  mild  cases.  When  added  to  milk  in  the  form 
of  blancmange  patients  usually  enjoy  it. 

Beef  tea  and  chicken  jelly  in  equal  parts  make  an  excellent  com- 
bination. 

Beverages  in  Fevers. 

The  Value  of  Water  and  Other  Beverages.— In  almost  all 
febrile  affections  the  liberal  use  of  water,  or  some  beverage  com- 
posed chiefly  of  water,  is  to  be  recommended  both  for  the  relief  of 
thirst  and  on  account  of  its  diluent  effect  and  of  its  increasing  the 
facility  with  which  the  waste  matter  resulting  from  the  rapid  metab- 
olism of  the  fever  is  eliminated  through  the  kidneys.  A  dry  mouth 
destroys  the  appetite.  It  is  believed  by  many  that  the  toxines  pro- 
duced by  the  action  of  typhoid-fever  germs  or  other  micro-organisms 
are  rendered  less  powerful  and  are  in  some  degree  "  washed  out " 
of  the  system  by  the  imbibition  of  large  draughts  of  water.  Patients 
who  are  extremely  feeble,  or  who  are  not  wholly  rational,  may  not 
ask  for  drink  although  their  mouths  are  dry  and  parched,  and  it 
should  always  be  the  duty  of  the  nurse  to  give  water  in  proper 
amount  at  regular  intervals.  In  long-continued  fevers  there  is  a 
tendency  for  an  increased  loss  of  water  from  the  surface  of  the  lungs, 
and  sometimes  from  the  skin,  although  the  kidneys  may  be  less  active 
than  normal,  and  if  care  is  not  taken  to  replace  the  fluid  in  the  body 
the  effects  of  this  loss  become  much  more  pronounced.  If  there  are 
profuse  watery  evacuations  from  the  bowels  the  drain  of  fluid  from 
the  blood,  and  eventually  from  other  body  tissues,  is  considerable. 

Sour  lemonade  constitutes  one  of  the  most  useful  and  refreshing 
beverages.  It  is  not  particularly  apt  to  disorder  the  stomach,  espe- 
cially if  taken  in  the  intervals  between  the  ingestion  of  food,  and  to 
many  persons  it  is  exceedingly  grateful.  It  may  be  made  efferves- 
cing by  the  addition  to  a  strong  lemonade  of  Vichy,  carbonic-acid 
water,  soda  water,  or  ten  grains  of  sodium  bicarbonate. 

Barley  and  rice  water  with  a  little  lemon  juice  and  sugar,  or  with 
cinnamon,  wine,  and  sugar,  afford  refreshing  drinks  to  many  persons, 
especially  children,  but  they  contain  very  little  nourishment.  Either 
tea  or  coffee  may  be  allowed  once  a  day  in  many  cases  of  fever,  al- 
though this  fact  is  often  overlooked.  Tea  should  be  avoided  if  there 
is  marked  indigestion  in  the  stomach,  and  coffee  as  well  as  tea  should 
be  avoided  in  cases  where  there  is  insomnia  or  excessive  nervousness. 
If  there  is  flatulency  they  should  be  given  without  sugar,  and  not  with 
other  food.  Many  persons  who  object  to  the  taste  of  milk  will  often 
take  it  contentedly  if  a  tablespoonful  of  good  coffee  be  added  to  the 
tumblerful.     Strong  black  coffee,  moreover,  is  useful  in  controlling 


DIET   IN   FEVER   IN   GENERAL. 


393 


vomiting,  and  is  mildly  stimulating  in  cases-of  heart  failure.  Its  diu- 
retic action  is  also  valuable  in  fever,  but  it  should  be  remembered  that 
persons  who  are  not  ordinarily  disagreeably  affected  by  the  daily  use 
of  strong  coffee  may  be  made  very  nervous  by  even  small  quantities 
given  when  the  system  is  reduced  by  the  wasting  processes  of  fever. 
Both  tea  and  coffee  should  be  used,  therefore,  with  discretion,  al- 
though they  may  at  times  prove  valuable  in  relieving  the  monotony 
of  a  fluid  diet.  Other  useful  beverages  are  whey,  or  whey  and  beef 
tea,  either  hot  or  iced,  and  unfermented  grape  juice. 

For  the  immediate  relief  of  thirst  cracked  ice  may  be  given, 
but  it  sometimes  parches  the  lips.  Some  patients  prefer  a  glycerin 
mixture.  A  drachm  or  two  of  glycerin  and  half  a  drachm  of  borax 
or  boric  acid  may  be  added  to  a  tumbler  of  water  and  used  to  rinse 
the  mouth. 

By  sipping  fluids,  thirst  is  more  relieved  than  if  they  are  quickly 
drunk.  There  is  more  satisfaction  in  being  allowed  to  drain  a  small 
glass  than  in  merely  taking  a  few  mouthfuls  from  a  large  tum- 
blerful. 

The  question  of  the  temperature  at  which  milk  or  any  form  of 
beverage  should  be  given  in  fevers  may  safely  be  left,  in  most  cases, 
to  the  liking  of  the  patient.  I  have  elsewhere  shown  (page  308)  that 
the  body  temperature  can  be  but  little  if  any  affected  by  that  of  in- 
gested fluids,  and  it  is  a  matter  of  far  more  importance  to  give  them 
in  so  agreeable  a  form  that  they  will  not  be  refused.  An  excess  of 
cold  drinks  may  embarrass  digestion  or  cause  stomach  cramps,  and 
should  be  avoided,  but  any  cold  fluid  slowly  sipped  will  do  no  harm. 

Alcohol  as  a  Food  in  Fevers. 

The  principal  theory  of  the  action  of  alcohol  in  all  fevers  is  that 
it  serves  as  a  food;  it  is  readily  absorbed  and  carried  in  the  blood  to 
all  parts  of  the  body,  and  it  is  believed  that  its  combustion  saves  in 
some  degree  the  wear  and  tear  of  the  tissues,  as  the  alcohol  burning 
in  a  spirit  lamp  furnishes  energy  in  the  form  of  heat,  and  itself  be- 
comes oxidised  to  waste  products,  but  spares  the  carbon  of  the  wick. 
The  latter  is  not  itself  burned  up  or  oxidised  until  the  alcohol  has  been 
exhausted.  Another  theory  of  the  use  of  alcohol  is  that  it  possesses 
a  positive  antipyretic  action  by  which  it  controls  the  body  tempera- 
ture by  restricting  heat  production.  It  is  also  believed  that  alcohol 
in  fevers  acts  upon  the  nervous  system,  strengthening  and  support- 
ing it,  in  this  manner  indirectly  controlling  the  nerve  currents  which 
preside  over  the  activity  of  nutrition,  chemical  change,  and  heat  pro- 
duction. The  subject  is  a  very  broad  one,  and  is  obscured  by  the 
lack  of  definite  knowledge  as  to  the  exact  nature  of  the  chemical 
processes   concerned   in  heat  production,  which  are  probably  very 


DIET   IN   DISEASE. 

complex.  It  is  possible  that  in  many  instances  alcohol  may  act  si- 
multaneously in  all  the  ways  suggested,  having  the  combined  effect  of 
a  food,  a  nerve  tonic,  and  an  antipyretic.  This  view  is  ably  advo- 
cated by  Dujardin-Beaumetz,  who  gives  an  exhaustive  discussion 
on  the  subject  in  his  work  on  alimentation  in  fevers  (Du  Regime 
Alimentaire  dans  les  Maladies  Febriles,  page  227). 

Light  white  wines,  diluted  claret,  and  even  beer  are  recommended 
in  fevers  by  some  writers  on  dietetics,  especially  in  those  countries 
in  which  good  water  is  unobtainable,  or  in  which  for  other  reasons 
wine  drinking  is  in  much  more  common  daily  use  than  it  is  in  Amer- 
ica, where  there  is  an  abundant  supply  of  pure  water.  In  France 
and  Germany  light  red  wine  is  frequently  allowed  throughout  the 
course  of  mild  fevers,  and  from  five  to  ten  ounces  are  given  daily. 

The  fever  diet  in  the  Munich  General  Hospital  includes  150  to 
300  grammes  of  light  red  wine  or  white  wine. 

Beer  is  also  much  used  in  Germany  for  fevers,  and  it  contains 
some  nourishment. 

If  alcohol  is  not  required  for  its  stimulating  effect  upon  the  cir- 
culatory or  nervous  systems  it  is  better  to  withhold  it,  for  in  con- 
tinued fevers  emergencies  may  at  any  time  arise  in  which  it  is  impera- 
tively demanded  to  strengthen  the  failing  powers  or  aid  in  controlling 
the  exhaustion  of  delirium.  Its  influence  will  always  be  more  de- 
cided and  its  action  can  be  much  better  controlled  if  spirits  have  not 
previously  been  given,  and  when  it  is  needed  for  any  such  reason  it 
is  best  to  prescribe  it  in  the  form  of  brandy  or  whisky. 

In  general,  it  may  be  stated  that  alcohol  is  usually  needed  if  the 
temperature  remains  for  several  days  above  103°  F.,  and  is  always 
required  if  it  remains  as  high  as  105°  F.  The  typhoid  condition 
supervening  in  the  course  of  any  fever  always  demands  it — i.  e.,  the 
condition  characterised  by  great  prostration,  low  muttering  delirium, 
subsultus,  rapid  feeble  pulse,  dry  tongue,  etc. 

In  the  convalescence  following  prolonged  fever  the  daily  use  of 
liquors  with  meals,  or  in  the  form  of  toddy  or  punches  between 
meals,  two  or  three  times  a  day,  is  often  indicated.  This  is  particu- 
larly the  case  among  elderly  people  convalescing  from  pneumonia 
and  other  acute  febrile  diseases  or  who  have  been  greatly  weakened 
by  some  prolonged  adynamic  disease.  In  infancy  also,  and  early 
childhood,  the  use  of  alcohol  may  be  demanded  in  the  course  of 
acute  fevers. 

•Persons  who  have  been  habitual  though  moderate  drinkers  for 
many  years,  or  throughout  their  lives,  when  attacked  with  any  severe 
acute  or  infectious  disease  possess  less  vitality  and  resistance  than 
those  whose  tissues  have  not  been  constantly  bathed  in  alcohol.  To 
withhold  the  long-accustomed  stimulation  in  these  cases  is  often  to 
precipitate  serious  exhaustion,  and  the  problem  of  properly  adapting 


DIET   IN   FEVER   IN   GENERAL. 


395 


the  quantity  of  alcohol  to  the  patients'  actual  needs  becomes  a  very 
serious  one  to  the  physician,  to  which  he  should  give  careful  and 
thorough  study.  Caution  should  be  given  against  the  continued  use 
of  alcohol  by  patients  in  whom  there  is  danger  of  inducing  the  alco- 
hol habit.  It  not  infrequently  occurs  that*  those  who  have  been 
addicted  to  excessive  drinking,  but  who  have  been  temporarily  cured 
of  the  habit,  and  who  have  taken  no  liquor  for  possibly  several 
years,  acquire  some  acute  disease  in  which  there  is  need  of  active 
stimulation.  In  such  cases,  having  in  view  the  possible  recovery  of 
the  patient,  with  a  renewal  of  his  alcoholic  habit,  this  stimulant 
should  be  withheld  as  long  as  possible  while  efforts  are  made  to  sus- 
tain the  enfeebled  heart  power  by  strychnine,  digitalis,  or  diffusible 
cardiac  stimulants,  such  as  ether,  ammonium  carbonate,  aromatic 
spirits  of  ammonia,  camphor,  etc. 

From  the  above  account  it  appears  that  the  question  of  the  use 
of  alcohol  in  all  febrile  disorders  should  be  considered  from  two  chief 
standpoints,  embracing,  first,  its  value  as  a  food,  with  its  relation 
to  other  foods  and  to  nutrition  ;  second,  its  value  as  a  stimulant  and 
the  extent  to  which  it  may  be  replaced  or  re-enforced  by  drugs.  The 
continued  use  of  strong  alcohol  always  disorders  digestion,  and  since 
the  stomach  is  weakened  in  fevers,  it  is  more  susceptible  to  such 
influences,  and  this  is  an  additional  argument  for  not  employing  alco- 
hol in  a  routine  method,  but  for  saving  it  for  positive  indications, 
such  as  asthenia.  But  in  those  cases  in  which  the  battle  for  life  must 
be  waged  largely  with  stimulants  as  much  as  one  ounce  an  hour 
(twenty-four  ounces/^/-  diem)  of  brandy  or  whisky  must  sometimes 
be  given,  and  it  is  a  curious  fact  that  in  the  presence  of  high  fever 
patients  can  often  tolerate  such  dosage  without  the  indications  of 
alcoholic  poisoning  which  in  health  would  promptly  follow  the  use  of 
a  smaller  quantity. 

Diet  in  Convalescence  from  Fevers. 

Convalescents  who  have  long  subsisted  wholly  upon  fluids  must 
be  careful  in  resuming  solid  diet,  for  the  rapidity  of  recuperation  of 
the  digestive  organs  varies  very  much  in  different  persons,  and  taking 
meats  or  other  solid  foods  too  soon  may  cause  rise  in  temperature, 
rapid  heart  action,  and  possibly  visceral  congestion.  The  first  meat 
given,  therefore,  should  be  in  a  finely  subdivided  state,  such  as 
scraped  beef  or  minced  chicken. 

During  convalescence  from  protracted  fevers  the  more  easily  di- 
gested forms  of  starchy  foods  are  found  to  be  very  useful,  especially 
if  there  has  been  much  loss  of  weight.  Sago  and  tapioca  thoroughly 
cooked  and  served  with  cream  are  highly  nutritious,  and  dried  bread 
crumbs  rolled  through  a  fine  sieve  may  be  added  to  thicken  clear 
meat  broths.     Crackers  and  Zwieback  are  useful. 


396 


DIET   IN   DISEASE. 


Other  ingredients  which  may  be  added  to  thicken  soups  during 
convalescence  are  panada,  semolina,  tapioca,  and  macaroni.  Cus- 
tard puddings,  cooked  fruit,  wine  and  beef  jellies,  blancmange,  or 
baked  custard  may  be  allowed. 

Mush,  fine  hominy,  cornstarch,  farina,  and  boiled  rice,  with  beef 
juice,  can  be  ordered. 

The  following  dietary  will  serve  as  a  general  guide  for  feeding 
convalescents  from  fevers  of  ordinary  severity  in  which  special 
lesions  of  the  alimentary  canal  are  not  present.  It  is  taken  from  a 
Handbook  of  Invalid  Cooking: 

■'  FIRST  DAY. 

*^  Breakfast. — Poached  t%%  on  toast.     Cocoa. 

^^  Lunch. — Milk  punch. 

*^  Dinner. — Raw  oysters.     Cream  crackers.     Light  wine  if  desired. 

*^  Lunch. — One  cup  of  hot  beef  broth. 

"  Supper. — Milk  toast.     Wine  jelly.     Tea. 

"SECOND  DAY. 

^'■Breakfast. — Soft-cooked  &g%.  Milk  punch.  Coffee  with  sugar 
and  cream. 

'■'■Lunch. — One  cup  of  soft  custard. 

^^  Dinner. — Cream-of-celery  soup.  Sippets  of  toast.  A  little  bar- 
ley pudding,  with  cream.     Sherry  wine  if  desired. 

'■'■Lunch. — Milk  punch. 

"  Supper. — Water  toast,  buttered.     Wine  jelly.     Tea. 

"THIRD  DAY. 

^^  Breakfast. — Scrambled  ^gg.     Cream  toast.     Cocoa. 

'■'Lunch. — One  cup  of  hot  chicken  broth. 

"Dinner. — Chicken  panada.  Bread.  Light  wine  if  desired.  A 
little  tapioca  cream. 

"  Lunch. — An  eggnog. 

•'  Supper. — Buttered  dry  toast.  Baked  sweet  apples  and  cream. 
Tea. 

"FOURTH  DAY. 

"  Breakfast.~Kn  orange.  Oatmeal  (H.  O.),  with  cream  and  sugar. 
Poached  egg  on  toast.     Baked  potato.     Cocoa. 

"  Lunch. — One  cup  of  hot  soft  custard. 

"Dinner. — Potato  soup.  Croutons.  A  small  piece  of  beefsteak. 
Creamed  potatoes.     Baked  custard.     Coffee. 

"Lunch. — One  cup  of  chicken  broth,  with  rice. 

"  Supper. ~^di^  oysters.  Banquet  crackers.  Graham  bread, 
toasted.     Wine  jelly.     Tea. 


TYPHOID  FEVER.  307 

"FIFTH  DAY. 

'^  Breakfast.— hx^  orange.  Coffee.  Oatmeal,  with  cream  and 
sugar.     Broiled  mutton  chop.     Toast. 

^^  Lunch. — One  cup  of  mulled  wine. 

"Z)/««^r.— Chicken  soup.  Bread.  Creamed  sweetbreads.  Duch- 
ess potato.     Snow  pudding.     Cocoa. 

"  Lunch. — Siphon  soda,  with  coffee  sirup  and  cream. 

"  6'«//^r.— Buttered  dry  toast.  Orange  jelly.  Sponge  cake  and 
cream.     Tea." 

A  further  discussion  of  this  topic  will  be  found  in  the  section 
upon  Convalescence  in  Typhoid  Fever. 

While  brandy  and  whisky  constitute  the  best  form  in  which  to 
give  alcohol  in  the  acute  stage  of  fevers,  in  convalescence  it  is 
often  advisable  to  use  some  other  alcoholic  drink,  and  an  occasional 
change  from  one  variety  to  another  renders  the  patient  somewhat 
less  liable  to  the  danger  of  acquiring  a  permanent  alcoholic  habit. 
For  convalescence,  if  the  patient's  purse  can  afford  it,  champagne, 
port  wine,  sherry,  Madeira,  or  a  good  claret  or  Burgundy,  may  be 
taken  with  advantage  in  the  class  of  cases  above  mentioned. 


TYPHOID   FEVER. 

Pathological  Physiolog^y. — Careful  nursing  and  diet  regula- 
tion are  the  life-saving  agents  in  typhoid  fever.  In  few  diseases 
does  a  closer  relation  exist  between  right  feeding  and  symptoms. 

In  average  cases  the  fever  lasts  a  month,  no  matter  what  the 
treatment,  whether  by  cold  bathing  or  otherwise,  while  in  some  it 
continues  for  five  or  even  six  weeks.  There  is  then  a  convalescent 
period  of  at  least  two  weeks,  and  often  as  many  months,  during  all 
which  time  constant  care  in  feeding  must  be  exercised.  At  any 
time  during  the  prevalence  of  the  fever  the  slightest  departure  from 
the  strict  rules  for  diet  laid  down  by  the  physician  may  determine  a 
fatal  issue,  but  it  is  during  the  period  of  ulceration  that  the  greatest 
danger  is  met. 

The  ulcers  involve  the  Beyer's  patches  and  solitary  follicles  in 
the  lower  end  of  the  ileum,  but  they  may  extend  into  the  jejunum, 
and  even  into  the  large  intestine.  They  are  deep  and  clean-cut, 
often  including  the  whole  thickness  of  the  muscular  layers,  and  some- 
times perforating  through  the  serous  layer.  An  overloaded  intes- 
tine or  a  distended  bowel  may  precipitate  perforation  at  any  mo- 
ment. It  is  therefore  important  to  select  a  diet  which  will  leave  but 
small  residue. 

More  or  less  intestinal  as  well  as  gastric  catarrh  is  often  present, 
interfering  with  both  digestion  and  absorption. 


393 


DIET   IN   DISEASE. 


The  prolonged  fever  is  itself  a  menace  to  life  by  the  secondary 
changes  which  it  induces  in  the  alimentary  system.  The  digestive 
secretions  are  altered  in  quality  and  lessened  in  quantity.  En- 
feebled circulation  retards  or  inhibits  absorption,  and  the  functional 
activity  of  the  liver  is  in  abeyance. 

Poisonous  products  suspended  in  the  blood,  as  well  as  its  ele- 
vated temperature,  interfere  with  the  normal  rate  of  metabolism 
through  the  body,  and  finally  the  excretory  organs  are  overworked. 

Dietetic  Treatment. 

There  are  two  chief  factors  which  should  influence  the  selection 
of  a  proper  diet  for  typhoid  fever.  These  are:  i.  The  supposed 
danger  of  mechanically  irritating  the  ulcerating  surfaces  in  the 
intestine  and  the  danger  of  overloading  an  intestine  and  stomach 
whose  digestive  functions  are  impaired  by  fever.  2.  The  relations 
of  the  chemical  ingredients  of  the  food  to  the  increased  tissue  change 
that  causes  or  accompanies  the  excessive  production  of  heat.  If  the 
proper  fuel  can  be  furnished  as  food,  the  tissues  are  spared  too  great 
self-consumption  in  producing  heat. 

Milk  Diet. — In  regard  to  the  first  factor  the  danger  of  mechan- 
ical irritation  of  the  intestinal  wall  is  somewhat  exaggerated.  In 
prescribing  a  milk  diet  for  typhoid  fever  in  order  to  lessen  this 
danger  many  overlook  the  fact  that  undiluted  milk,  on  entering  the 
stomach,  becomes  almost  solid,  and  large  firm  milk  curds  are  likely 
to  prove  quite  as  irritating  to  the  ulcerating  surfaces,  or  even  more 
so,  than  are  starchy  foods. 

When  patients  are  fond  of  milk  and  digest  and  absorb  it  thor- 
oughly, there  is  no  better  diet  for  typhoid  fever,  and  it  answers 
every  requirement  of  a  fever  food.  It  contains  all  the  essential 
elements  of  nutrition,  is  easily  digested,  furnishes  fluid  to  the  tis- 
sues, is  a  good  diuretic,  and,  if  properly  administered,  in  many  cases 
it  is  soothing  to  the  stomach  when  a  mild  degree  of  gastric  catarrh 
exists. 

Those  who  dislike  milk  at  first  may  later  grow  accustomed  to  it 
and  take  it  contentedly  for  a  month  or  even  six  weeks. 

Due  emphasis  should  be  given  to  the  fact  that  an  exclusive  milk 
diet  need  not  and  should  not  be  prescribed  in  routine  for  all  cases. 
Within  the  past  few  years  a  number  of  writers  have  advocated  a 
departure  from  the  strict  milk  diet  which  had  come  to  be  the  rule 
for  typhoid  fever,  and  it  is  found  beneficial  to  enlarge  the  dietary  of 
some  patients  considerably.  It  is  much  easier  to  put  all  hospital 
cases  of  typhoid  fever  on  a  routine,  milk  diet,  but  it  is  often  better 
to  devote  a  little  study  to  securing  suitable  variation  in  the  food. 

In  typhoid  fever  every  effort  should  be  made  to  maintain  good 
stomach  digestion.     If  all  food  is  thoroughly  disintegrated  before  it 


TYPHOID   FEVER. 


399 


enters  the  intestine  there  need  be  little  fear  of  a  mechanical  irrita- 
tion of  the  ulcerating  surfaces.  Far  more  danger  may  occur 
through  malnutrition  of  the  intestinal  wall,  which  prevents  absorp- 
tion of  nutriment.  An  accumulation  of  undigested  food  in  the 
intestine  is  therefore  highly  undesirable,  and  the  stools  should  be 
periodically  examined  to  see  that  undigested  milk  curds  do  not 
appear  in  them. 

Milk  for  some  persons  in  health  is  really  a  poison.  They  com- 
pletely fail  to  digest  it.  It  causes  constipation  with  clay-coloured  or 
white  stools,  and  fills  the  bowels  with  products  of  malfermentation, 
ptomaines,  and  gases.  They  digest  it  even  less  when  they  acquire 
a  prolonged  fever.  Others,  with  whom  the  milk  agrees,  become 
very  tired  of  it  after  taking  it  exclusively  for  several  weeks  at  a 
time. 

I  have  several  times  seen  cases  of  typhoid  fever  with  symptoms 
which  resembled  scurvy,  with  swollen  and  bleeding  gums  and  great 
emaciation,  occurring  in  patients  who  had  been  fed  too  long  upon 
an  exclusive  milk  diet  which  they  failed  to  assimilate. 

Quantity  of  Milk  required. — If  milk  is  the  oply  food,  enough 
should  be  given,  and  the  problem  of  what  constitutes  enough  must 
be  solved  in  each  case  separately.  Much  harm  is  done  by  overfeed- 
ing, which  induces  indigestion  and  restlessness,  increases  the  pulse 
rate,  and  aggravates  the  abdominal  symptoms — such  as  tympanites, 
diarrhoea  or  constipation,  haemorrhage,  and  abdominal  pain.  Inges- 
tion is  very  different  from  digestion. 

There  are  many  writers  upon  dietetics  who  give  a  special  cau- 
tion against  the  practice  of  overfeeding  in  cases  of  enteric  fever  on 
account  of  the  fact  that  more  or  less  gastric  catarrh  is  usually  pres- 
ent and  that  it  is  an  undue  tax  upon  the  digestion  of  the  patient  to 
have  to  deal  with  a  large  bulk  of  food. 

On  the  other  hand,  underfeeding  causes  malnutrition,  favours  the 
occurrence  of  complications,  and  prolongs  convalescence. 

For  an  exclusive  milk  diet  the  outside  limits  lie  between  one 
and  three  quarts /^r  ^/V'w,  depending  somewhat  upon  the  age  and 
size  of  the  individual,  but  more  upon  the  condition  of  his  digestion. 
A  clean  tongue,  a  soft  abdomen,  and  natural  milk  stools,  not  too 
hard  and  without  coagulae  of  casein  or  flakes  of  fat,  indicate  that  the 
milk  is  being  well  digested. 

The  reverse  of  these  symptoms  suggests  that  the  milk  is  supplied 
in  too  large  quantity,  or  that  it  is  not  being  digested,  and  one  or 
more  of  three  things  must  be  done:  (a)  The  quantity  must  be  re- 
duced; (/^)  the  mode  of  administration  must  be  changed— i.  e.,  the 
milk  must  be  "  prepared  "  or  "  predigested  "  ;  (c)  other  foods  must  be 
substituted,  either  wholly  or  in  part. 

{a)  When    milk   appears   to    be  well    digested,   but   the   patient 

28 


.QQ  DIET    IN    DISEASE. 

emaciates  rapidly  early  in  the  disease,  he  is  not  getting  nourishment 
enough,  and  the  quantity  must  be  increased  or  other  food  must  be 
added.  As  a  general  rule,  from  one  and  three  fourths  to  two  quarts 
of  milk  per  diem  (or  six  ounces  every  two  hours,  day  and  night), 
however  diluted,  is  sufficient  during  the  height  of  the  fever  to  sus- 
tain the  patient  properly.  It  is  best  to  give  as  much  as  can  be 
thoroughly  assimilated  according  to  the  symptoms  above  noted. 

Johnston  believes  that  from  three  to  four  ounces  of  milk  given 
every  two  or  three  hours  is  sufficient.  Moore  states  that  very  few 
patients  digest  over  one  and  a  half  to  two  pints  of  milk,  and  "  it  is 
scarcely  ever  necessary  to  exceed  the  amount  of  one  quart  of  milk 
in  the  twenty-four  hours,"  or  three  ounces  of  milk  in  ten  feedings  at 
intervals  of  two  and  a  half  hours.  This  estimate,  for  uncomplicated 
cases  at  least,  is  too  low.  It  may  be  necessary  to  reduce  the  allow- 
ance to  .this  figure  if  severe  gastro-intestinal  disturbance  occurs,  or, 
in  fact,  with  violent  vomiting  to  temporarily  discontinue  the  milk 
entirely,  and  give  only  cracked  ice  or  half-ounce  doses  of  iced  cham- 
pagne, but  patients  kept  too  long  on  as  low  a  diet  as  that  mentioned 
will  emaciate,  grow  feeble  to  an  alarming  degree,  and  require  exces- 
sive stimulation. 

{p)  The  milk  may  be  given  raw,  boiled,  diluted  with  plain  water, 
barley  water,  lime  water,  Vichy,  Seltzer,  or  ApoUinaris,  or  pancreatin- 
ised  according  to  taste  and  need.  Gelatin,  as  well  as  gum  arable,  is 
sometimes  added  to  milk  to  dilute  it  and  prevent  tough  curds  from 
forming.  The  milk  should  never  be  skimmed.  Its  taste  may  be  dis- 
guised by  the  addition  of  a  little  strong  coffee  or  some  of  the  extract 
of  coffee,  or  a  little  caramel  makes  it  agreeable  to  the  taste  where 
patients  have  refused  it  before,  or  it  may  occasionally  be  preferred 
with  a  cup  of  cocoa  in  which  the  milk  predominates.  If  diarrhoea  is 
present,  a  milk  diet  is  especially  useful,  and  the  milk  should  be  boiled. 

When  vomiting  occurs,  it  is  better  to  use  peptonised  or  pancre- 
atinised  milk  than  soda  or  lime  water,  for  the  latter  tend  to  neu- 
tralise the  activity  of  an  already  enfeebled  gastric  juice.  These 
fluids  may  be  given  either  hot  or  cold,  according  to  taste.  If  cold, 
the  nausea  is  sometimes  controlled,  but  digestion  may  be  somewhat 
retarded.  If  the  vomiting  is  very  obstinate,  koumiss,  kefir,  or  mat- 
zopn  may  be  given  for  a  time  with  very  good  result  in  place  of 
milk.  Whey  or  buttermilk  is  also  used  sometimes  for  a  change  for 
a  few  days.  Loomis  recommended  from  four  to  six  quarts  of  the 
latter/^/-  diem. 

{c)  Substitutes  for  Milk  Diet. — When  milk  is  obviously  dis- 
agreeing and  producing  flatulence,  I  have  often  seen  improvement 
follow  an  entire  change  of  diet  for  a  day  or  two  to  animal  broths. 
Similar  results  are  familiar  in  the  treatment  of  infantile  diarrhoea. 

In  cases  like  those  above  described  in  which,  after  fair  trial,  it  is 


TYPHOID   FEVER. 


401 


found  impossible  to  urge  upon  the  patient  the  taking  of  milk,  there 
is  no  objection  to  giving  strained  broths  of  mutton,  chicken,  or  beef 
a  little  clam  broth  for  a  relish,  and  light  farinaceous  articles,  such  as 
the  prepared  starchy  foods,  like  Mellin's  or  Nestle's,  barley  water, 
farina,  arrowroot,  and  other  gruels,  custards,  eggnog,  or  a  piece  of 
Zwieback  softened  by  soaking  in  milk,  weak  tea,  or  bouillon.  I  have 
recently  used  gruel  made  from  banana  meal,  which  is  palatable,  highly 
nutritious,  and  easily  digested  (see  page  164).  Junket  and  cream 
are  very  nutritious  and  agreeable  to  the  palate.  Egg  albumen  can 
be  made  very  palatable  by  beating  it  with  a  little  milk  and  sherry. 
In  this  manner  considerable  variety  is  secured  for  the  patient;  the 
appetite,  and  in  many  cases  the  digestion,  are  improved,  and  by  alter- 
nating one  or  more  of  these  articles  with  the  milk,  a  much  larger 
quantity  of  nourishment  will  in  the  end  be  taken  and  absorbed 
Layton  estimates  that  typhoid  patients  may  sometimes  lose  half  a 
pound  in  weight  per  diem,  and  in  that  class  of  cases  in  which  rapid 
emaciation  is  a  most  alarming  feature  of  the  disease  these  various 
adjuncts  to  the  milk  diet  are  especially  useful.  Moreover,  patients 
fed  in  this  manner  are  not  apt  to  become  ravenous  during  convales- 
cence. 

It  is  well  expressed  by  Henry  that  "it  is  not  so  much  solid  as  in- 
digestible food  that  should  be  eschewed,  and  it  should  never  be  for- 
gotten that  all  foods  except  such  as  are  predigested  are  solid  in  the 
first  stage  of  digestion."  A  pint  of  milk  contains  as  much  solid 
material  as  a  mutton  chop. 

The  continued  use  of  beef  tea,  beef  juice,  or  meat  extracts  and 
peptonoids  undoubtedly  produces  loosening  of  the  bowels,  and  such 
substances  must  be  avoided  when  diarrrhoea  is  present;  but  in  cases 
where  there  is  a  tendency  to  constipation  this  may  be  a  decided  ad- 
vantage. Veal  and  chicken  broth  are  much  less  apt  to  have  a  laxa- 
tive effect  than  beef  and  mutton  broth,  and  calf's-foot  jelly  is 
allowed  by  some  clinicians.  When  patients  tire  of  the  taste  of  beef 
tea  or  broth  it  may  be  flavoured  with  a  little  celery  salt  or,  if  there 
is  no  diarrhoea,  with  a  very  little  tomato  juice  or  other  simple  vege- 
table extract. 

Henry  advocates  the  use  of  gelatin  as  an  "albumin  sparer," 
although  it  should  not  be  given  if  diarrhoea  is  present.  As  much  as  a 
claret-glass  full  may  be  given  on  alternate  days,  and  it  can  be  in  the 
form  of  simple  blancmange  or  peptonised  milk  jelly,  which  is  made 
by  adding  while  hot  gelatin  dissolved  in  a  little  water  to  peptonised 
or  pancreatinised  milk,  and  flavouring  with  lemon  or  orange  and 
sherry  or  rum.  It  is  eaten  cold.  In  the  stomach  it  is  quite  as  fluid 
as  predigested  milk. 

Farinaceous  Gruels. — I  have  alluded  to  the  occasional  advan- 
tage of  giving  farinaceous  gruels,  for,  despite  the  fact  that  many  writ- 


.Q2  DIET    IN   DISEASE. 

ers  are  opposed  to  them  on  the  ground  that  they  may  excite  tympany, 
I  believe  them  to  be  at  times  of  great  service.  Stromeyer  feeds  his 
patients  largely  upon  oaten  grits  boiled  for  three  hours  without  sugar. 

Da  Costa  recommends  giving  three  pints  of  milk  and  one  pint  of 
broth  every  twenty-four  hours,  with  a  midday  allowance  of  some 
gruel,  such  as  arrowroot.  There  is  a  variety  of  enteric  fever  in 
which  without  any  noticeable  complications,  and  even  without  a 
very  high  temperature  curve,  emaciation  is  rapid  and  extreme.  In 
such  cases  especially  the  use  of  farinaceous  gruels  is  indicated.  They 
must  not  be  given  too  sweet,  and  a  little  cream  or  lemon  juice  may 
be  added  in  lieu  of  sugar.  It  is  often  advisable  to  add  a  tablespoon- 
ful  of  malt  extract,  or  one  of  the  "prepared  foods,"  such  as  Mellin's, 
Horlick's,  Ridge's;  or  malted  milk  may  be  given  in  milk. 

Sleep  and  Food. — In  all  cases  of  typhoid  fever  the  question 
arises  in  regard  to  waking  the  patient  at  night  for  nourishment,  or  to 
take  the  temperature. 

Some  patients  awaken  easily,  are  fed,  and  drop  off  to  sleep  again 
almost  immediately.  They  may  be  fed  every  two  hours  day  and 
night.  Others,  if  awakened,  do  not  readily  fall  asleep  again,  and 
lose  half  the  night's  rest  or  more,  and  this  may  considerably,  retard 
their  recovery.  It  is  sometimes  best  to  let  them  sleep  for  three,  or 
even  four,  hours  without  being  aroused,  for  the  rest  may  be  of  more 
value  to  them  than  food.  So  much  depends  upon  the  temperature, 
pulse,  and  general  condition  of  each  case  that  no  rigid  rule  should 
be  formulated,  but  it  is  best  never  to  let  four  hours  pass  while  the 
fever  lasts  without  giving  food.  If  patients  are  told  that  they  have 
a  little  longer  interval  than  usual  in  which  to  rest  undisturbed,  they 
will  sometimes  go  to  sleep  at  once. 

Of  course,  if  they  sleep  during  the  day  there  is  less  need  of  post- 
poning feeding  by  night.  Constant  drowsine'ss  may  indicate  a  need 
of  more  food.  The  nurse  should  always  furnish  a  daily  record  of 
the  exact  amount  of  milk  or  broths  actually  given  in  twenty-four 
hours,  making  allowance  for  dilution,  and  this  should  be  compared 
with  the  quantity  of  urine  voided. 

Thirst. — Thirst  is  a  prominent  symptom  in  enteric  fever,  and 
cool  water  should  be  given  in  abundance  by  the  nurse,  without  wait- 
ing for  the  patient  to  ask  for  it.  Water  favours  nutrition  and  the 
elimination  of  waste.  If  diarrhoea  is  absent  it  is  well  to  acidulate 
the  water  with  a  little  dilute  phosphoric  or  hydrochloric  acid,  ten  or 
fifteen  drops  to  the  tumblerful,  or  water  flavoured  with  infusion  of 
orange  or  serpentaria.  Hoppe-Seyler  has  washed  out  the  stomach 
in  cases  of  typhoid  fever,  and  shown  that  while  the  temperature  re- 
mains high  there  is  little  or  no  acid  contained  in  the  gastric  juice, 
and  a  mildly  acidulated  beverage  may  prove  serviceable  by  aiding 
digestion  as  well  as  by  relieving  thirst. 


TYPHOID   FEVER. 


403 


Relief  of  the  latter  symptom  is  sometimes  sought  by  painting  the 
tongue  with  glycerin,  which  is  used  to  prevent  evaporation  from  the 
surface  and  not  because  of  any  special  virtue  in  the  glycerin  itself, 
which,  in  fact,  is  hygroscopic  and  tends  to  abstract  water  from  the 
mucous  surface  unless  it  is  already  very  much  diluted,  and  it  cannot 
protect  it  sufficiently  from  the  evaporation  which  occurs  in  mouth 
breathing.  The  use  of  cracked  ice  in  excess  aggravates  thirst  rather 
than  relieves  it,  and  it  is  better  to  sip  cool  water  at  a  temperature  of 
50°  to  60°  F.  rather  than  ice.  The  juice  of  a  sweet  orange  or  a 
lemon  is  often  very  acceptable,  and  in  the  absence  of  serious  com- 
plications it  can  do  no  harm.  Iced  tea  may  prove  agreeable.  As  a 
rule,  it  is  well  to  restrict  the  use  of  effervescent  drinks  for  the  con- 
trol of  thirst  on  account  of  the  danger  of  increasing  flatulency,  and 
stretching  the  ulcerated  intestinal  wall. 

In  addition  to  the  need  of  water  for  relieving  thirst,  it  is  of  great 
service  as  a  diluent  for  washing  out  the  waste  products  of  the  febrile 
action  from  the  system  through  the  kidneys.  Many  clinicians,  as 
Henry,  Meigs,  and  Beverley  Robinson,  make  it  a  special  feature  of 
their  treatment  to  give  large  draughts  of  water.  Henry  advises  giv- 
ing each  patient  eighty  ounces  of  water  (including  that  contained  in 
fluid  food)  per  diem,  and  Meigs  has  given  as  much  as  one  hundred 
and  thirty  ounces  with  benefit,  including  from  thirty  to  fifty  ounces 
of  free  water.  Debove  gives  six  ounces  every  two  hours.  It  should 
not  be  drunk  too  soon  after  the  fluid  food,  but  in  the  intervals,  so  as 
not  to  dilute  the  gastric  juice  too  much.  In  mild  cases  a  little 
coffee  or  a  cup  of  cocoa  may  be  drunk  in  the  morning. 

Alcohol. — The  question  of  how  far  alcohol  serves  the  purpose  of 
a  food  and  a  "  force  regulator  "  in  typhoid  fever  is  very  important. 
The  employment  of  it  in  excess  as  a  routine  treatment  is  greatly  to 
be  deplored.  It  is  seldom  required  at  all  in  the  first  fortnight. 
Later  the  heart  is  enervated  and  its  muscular  tissue  is  enfeebled. 
In  all  complications  which  threaten  life,  such  as  severe  haemorrhage, 
sudden  cardiac  dilatation,  hyperpyrexia  (107°  F.),  pneumonia,  or  un- 
controllable diarrhoea,  alcohol  must  be  given  without  stint.  When 
the  complication  is  passed  the  dosage  should  be  gradually  reduced. 

Patients  above  forty  years  of  age  usually  require  stimulation 
early. 

It  was  formerly  customary  to  prescribe  whisky  in  typhoid  fever 
at  the  rate  of  twenty  or  twenty-four  ounces  per  diem,  and  in  some 
chronic  alcoholic  patients  large  quantities  of  alcohol  may  be  needed 
to  prevent  collapse.  Sometimes  delirium  will  disappear  when  exces- 
sive dosage  of  alcohol  is  discontinued,  and  I  am  inclined  to  prescribe 
very  much  less  alcohol  than  formerly,  especially  for  young  and  ro- 
bust patients.  Undoubtedly  there  are  cases  of  greatly  weakened 
circulation  in  which  its  use  must  be  pushed  rapidly,  and  in  which  it 


.Q.  DIET   IN    DISEASE. 

quiets  restlessness,  insomnia,  and  delirium  better  than  opium  or 
other  narcotics,  but  it  is  not  to  be  forgotten  that  there  are  other 
valuable  cardiac  stimulants.  By  giving  small  doses  of  digitalis  or 
strophanthus,  or  the  two  in  combination,  by  the  use  of  caffeine,  cam- 
phor, small  doses  of  morphine,  and  other  remedies  in  combination 
with  alcohol,  much  less  of  the  latter  will  be  required,  and  there  is 
much  less  danger  of  inducing  the  alcohol  habit.  Strong  whisky 
often  intensifies  the  stomach  catarrh  and  interferes  with  the  natural 
absorption  of  food.  One  very  noticeable  feature  of  the  Brand  cold- 
bath  treatment  is  that  the  patients  do  well  with  so  little  alcohol, 
many  of  them  requiring  none  at  all  in  the  intervals  between  the 
baths. 

The  kind  of  alcoholic  stimulant  prescribed  must  depend  upon  the 
circumstances  of  the  case.  Brandy  and  whisky  possess  the  advan- 
tage that  the  dosage  is  more  uniform  and  the  bulk  is  not  great.  It 
is  a  matter  of  routine  hospital  practice,  founded  largely  on  econom- 
ical reasons,  to  give  whisky  or  brandy  as  the  only  form  of  alcho- 
holic  stimulation,  but  in  private  practice,  especially  among  women, 
liquors  may  be  distasteful,  and  equally  good  results  can  be  ob- 
tained by  ordering  some  good  strong  wine  which  is  more  agree- 
able to  the  taste,  such  as  one  of  the  Hungarian  wines,  Malaga,  port, 
sherry,  claret,  etc.  In  Germany  patients  are  often  allowed  beer, 
but  this  beverage  is  open  to  the  same  objection  as  the  effervescent 
drinks,  for  there  is  more  or  less  gastric  catarrh  usually  present.  It 
is  not  much  prescribed  in  this  country.  It  serves  better  during  con- 
valescence than  while  the  fever  is  present.  Brandy  in  milk  or  soda 
or  Seltzer  water  is  best  for  diarrhoea,  and  dry  champagne  is  good  if 
there  is  vomiting.  As  the  latter  is  used  in  small  doses — an  ounce  or 
less  at  a  time — it  is  economical  to  place  a  patent  cork  with  a  faucet 
in  the  bottle,  so  that  a  little  may  be  drawn  at  a  time  without  losing 
all  the  effervescence.  In  any  case  in  which  alcohol  is  given  the  best 
guides  for  the  proper  quantity  are  found,  as  in  pneumonia,  in  the 
breath,  delirium,  tongue,  and  pulse.  If  the  breath  has  no  odour 
of  alcohol  an  hour  or  two  after  the  dose  has  been  taken,  if  delir- 
ium has  subsided,  if  the  tongue  becomes  more  moist,  and  the 
pulse  becomes  more  full  and  slow,  the  alcohol  is  doing  good. 

During  convalescence  a  little  alcohol— three  ounces  of  whisky 
or  four  or  five  of  Burgundy  a  day,  for  example— may  be  needed  as  a 
tonic,  but  should  be  given  only  with  food. 

Relation  of  Intestinal  Antisepsis  to  Diet. 

It  is  said  that  bacilli  fed  on  beef  juice  produce  ptomaines 
which  act  more  strongly  upon  the  nervous  system  than  if  they  are 
fed  upon  milk  (Rachford).     The  .starches  do  not  make  ptomaines. 

The   typhoid   germs  certamly  thrive   in   nitrogenous  media,  but 


TYPHOID   FEVER. 


40.5 


not  upon  carbohydrates.  Their  development  in  the  former  is  ac- 
companied by  the  production  of  toxic  material  in  the  intestine, 
which,  on  being  absorbed  into  the  system,  produces  the  symptomatic 
phenomena  of  the  disease.  This  theory,  which  is  of  comparatively 
recent  adoption,  has  emphasised  the  possible  value  of  antiseptic 
treatment  of  the  alimentary  canal.  While  there  are  as  yet  no  reme- 
dies known  to  therapeutics  which  can  be  used  in  sufficient  strength 
in  the  intestine  to  be  completely  antiseptic  or  germicidal  to  the 
typhoid  bacilli,  there  is  another  aspect  of  antisepsis,  or  rather  asep- 
sis, of  the  alimentary  canal,  which  should  not  be  overlooked — that  is, 
the  prevention  of  those  fermentative  changes  which  accompany  in- 
digestion in  any  fever.  In  typhoid  fever  the  importance  of  main- 
taining as  nearly  as  possible  the  normal  digestion  and  absorption  of 
the  food  is  of  special  urgency  on  account  of  the  length  of  the  dis- 
ease. Moreover,  it  would  appear  that  the  overdistention  of  the  in- 
testine by  flatus  must  have  a  very  injurious  effect  upon  the  ulcerat- 
ing surfaces  by  stretching  them.  At  autopsies  upon  typhoid  patients 
ulcers  are  often  seen  which  might  have  been  easily  torn  by  slight 
distention,  and  the  prognosis  of  typhoid  fever  is  more  grave  when 
extreme  and  obstinate  intestinal  flatulency  appears  early  in  the  dis- 
ease, before  there  has  been  time  for  either  perforation  or  peritonitis. 
One  can  do  much  to  prevent  this  condition  by  bestowing  special  care 
upon  the  whole  alimentary  canal. 

Care  of  the  Mouth. — The  mouth  should  be  washed  very  fre- 
quently at  regular  intervals,  and  always  after  taking  a  glass  of  milk, 
for  nothing  coats  the  tongue  more  than  a  milk  diet,  or  forms  a 
better  field  for  the  development  of  bacteria,  which  are  constantly 
being  carried  down  to  the  stomach  to  excite  indigestion  and  flatu- 
lency there.  Listerine  in  the  proportion  of  a  teaspoonful  to  a  claret- 
glass  full  makes  a  most  satisfactory  and  cleansing  mouth  wash.  A 
whalebone  bent  in  a  loop  forms  a  good  "  tongue  scraper,"  and  cleans 
its  surface  quite  thoroughly.  If  patients  are  too  feeble  to  rinse  the 
mouth,  the  nurse  should  swab  it  out  for  them  with  a  bit  of  cotton. 
Nurses  should  be  made  to  understand  the  importance  of  this  simple 
detail,  for,  if  properly  attended  to,  it  adds  greatly  to  the  patient's 
comfort  and  appetite.  When  this  is  faithfully  done,  one  seldom 
sees  even  in  fatal  cases  a  typical  "  typhoid  tongue  " — brown,  dry,  hard, 
fissured,  and  so  stiff  that  it  is  useless  to  the  patient.  Patients  can 
often  learn  to  use  a  tongue  bath  to  advantage — that  is,  to  hold  the 
mouth  full  of  fluid  for  several  minutes  at  a  time,  when  such  mois- 
ture is  absorbed  by  the  mucous  membrane.  The  proper  care  of  the 
mouth  will  greatly  lessen  the  liability  to  parotiditis  and  catarrh  of 
the  middle  ear. 

The  Stomach.— The  dangers  of  overfeeding  with  milk  have 
already  been  considered  above  (paje  399).    Milk  disagrees  with  many 


4o6 


DIET   IN   DISEASE. 


patients  sooner  or  later,  and  the  fermentation  processes  of  which 
it  is  capable  produce  large  quantities  of  gas  and  sometimes  eleva- 
tion of  temperature.  Small  doses  of  salicin  or  cerium  oxalate  with 
each  tumbler  of  milk  often  prevent  dyspepsia,  and  the  milk,  if  steril- 
ised, may  be  retained  and  digested  where  vomiting  has  been  ex- 
treme. If  there  is  the  least  indication  of  ordinary  milk  disagreeing, 
it  should  be  at  once  changed  for  some  other  form — peptonised,  or 
sterilised,  or  boiled.  With  a  clean  tongue,  and  with  sterilised* milk 
in  the  stomach,  much  may  be  done  to  favour  the  further  digestion  of 
milk  in  the  intestine. 

The  Intestine. — Many  typhoid  patients  are  severely  consti- 
pated by  an  exclusive  milk  diet.  Constipation  favours  abnormal 
fermentation,  and  begets  the  flatulency  which  is  so  injurious.  Such 
cases  should  not,  as  a  rule,  be  allowed  to  go  more  than  forty-eight 
hours  without  encouraging  a  movement  with  an  enema.  While  rt  is 
not  possible  to  render  the  alimentary  canal  in  any  sense  truly  aseptic 
throughout,  a  great  deal  may  be  done  to  favour  the  vital  conditions 
of  nutrition  by  preventing  the  opposite  extreme  of  excessive  inges- 
tion of  bacteria  of  various  kinds  and  the  production  of  malfermenta- 
tion.  This  appears  to  be  at  present  a  more  encouraging  field  for 
germicidal  efforts  than  treatment  directed  against  the  seat  of  war  in 
the  Peyer's  patches.  The  judicious  daily  use  of  rectal  enemata  never 
excites  intestinal  haemorrhage,  but  excessive  constipation  provokes 
meteorism,  stretches  the  thin  ulcerating  surfaces  to  the  point  of 
rupture,  and  tends  to  keep  the  temperature  elevated.  If  relapses  are 
due  to  reinfection  or  to  simple  septic  absorption  through  ulcerating 
intestinal  surfaces,  there  is  all  the  more  reason  for  the  prevention  of 
accumulation  of  too  much  food  in  the  intestine.  The  recent  good 
results  with  salol  as  an  intestinal  antiseptic  have  led  to  its  employ- 
ment in  typhoid  fever  with  much  benefit  to  prevent  meteorism.  It 
should  be  given  in  capsules  of  two  grains  every  three  hours  to  check 
abnormal  fermentation  of  milk. 

Convalescence. — As  the  fever  subsides,  it  becomes  an  impor- 
tant question  how  soon  to  allow  a  return  to  solid  food.  Relapses 
are  very  easily  induced  by  indiscretion  in  this  regard. 

The  patient's  appetite  is  always  a  dangerous  guide  to  follow  in 
this  disease.  After  four  or  five  weeks  of  an  exclusive  milk  or  milk 
and  broth  diet,  when  the  temperature  subsides,  and  often  before  it 
has  become  normal,  he  becomes  ravenous.  Like  a  long-starved  man, 
he  thinks  of  nothing  but  food,  and  demands  something  new  to  eat 
every  day.  A  hospital  ward  containing  a  dozen  convalescing  ty- 
phoid-fever patients  is  difficult  to  manage,  as  a  bread  riot  is  con- 
stantly menaced.  Ill-advised  but  sympathetic  friends  attempt  to 
smuggle  in  all  manner  of  forbidden  fruits,  and  the  patient  just  ar- 
rived at  the  hungry  stage  is  tempted  to  steal  solid  food  from  his 


TYPHOID   FEVER. 


407 


mere  advanced  neighbour.  I  have  seen  critical  relapses  brought  on 
by  surreptitiously  eating  ginger  snaps,  or  a  few  grapes,  or  a  raw 
apple,  and  in  one  instance  a  young  girl  who  had  cried  in  vain  for 
solid  food  ate  all  the  flowers  which  some  member  of  the  "  Flower 
Mission  "  had  kindly  placed  by  her  pillow !  But  it  is  only  fair  to 
state  that,  strange  as  it  may  sefem,  she  escaped  a  relapse. 

Some  authors  advocate  always  postponing  the  return  to  solid 
food,  especially  butcher's  meat,  for  two  weeks  after  the  temperature 
has  reached  and  remained  at  the  normal  for  a  day  or  two.  Fagge 
says :  "  No  solid  food  should  be  given  for  a  fortnight  after  fever 
and  diarrhoea  have  ceased,"  and  no  doubt  in  very  feeble  and  anaemic 
patients  and  those  who  have  suffered  from  haemorrhage  one  cannot  be 
too  careful  in  withholding  solids  for  ten  days  at  least  after  the  tem- 
perature has  fallen  to  below  100°  F.  But  in  the  milder  cases  it  is 
undoubtedly  both  safe  and  wise  to  allow  a  more  strengthening  diet 
at  an  earlier  date,  and  it  will  greatly  prolong  convalescence  to 
forbid  it.  Peabody  advocates  giving  carefully  prepared  scraped 
beef  two  or  three  days  after  subsidence  of  the  temperature.  Osier 
is  opposed  to  giving  meat  in  any  form  early,  for  he  finds  it  apt 
to  disagree  or  excite  a  "  febris  carnis."  Additional  light  farinaceous 
diet — tapioca,  rice,  vermicelli,  cream  toast,  a  cracker  soaked  in 
cream,  etc. — may  next  be  given  with  impunity  in  cases  which  have 
run  a  mild  course.  Meat  broths  may  be  thickened  with  rice,  sago, 
or  vermicelli.  In  a  day  or  two  more  the  soft  part  of  oysters  or  a 
chop  are  permissible.  In  cases  which  have  presented  no  serious 
complications,  if  there  is  good  stomach  digestion  there  is  no  need 
of  prolonging  a  fluid  diet  for  fear  of  intestinal  injury. 

The  following  is  a  list  of  foods  suitable  for  the  different  days  of 
convalescence,  commencing  a  day  or  two  after  disappearance  of  all 
fever.  Milk  should  still  be  given  until  gradually  wholly  replaced  by 
solid  food. 

First  Day. — Chicken  broth  thickened  with  thoroughly  boiled  rice. 
Milk  toast  or  cream  toast.     Once  only  during  the  day. 

Second  Day. — Junket,  mutton  broth,  and  bread  crumbs.  Milk 
toast.     A  piece  of  tender  steak  may  be  chewed  but  not  swallowed. 

Third  Day. — A  small  scraped-beef  sandwich  at  noon.  A  soft- 
cooked  egg  or  baked  custard  for  supper. 

Fourth  Day. — The  soft  part  of  three  or  four  oysters.  Meat  broth 
thickened  with  a  beaten  0.%^.  Cream  toast.  Rice  pudding  or  blanc- 
mange and  whipped  cream,  or  Bavarian  cream. 

Fifth  Day. — Scraped-beef  sandwich.  A  tender  sweetbread.  Bread 
and  milk.     A  poached  egg.     Calf's-foot  jelly. 

Sixth  Day. — Mush  and  milk,  scrambled  eggs,  chicken  jelly.  Bread 
and  butter. 

Seventh  Day. — A  small  piece  of  tenderloin  steak  or  a  little  breast 


408 


DIET   IN   DISEASE. 


of  broiled  chicken.  Bread  and  butter.  Boiled  rice.  Wine  jelly. 
Sponge  cake  and  whipped  cream. 

Eighth  Day. — A  slice  of  tender  rare  roast  beef,  a  thoroughly 
baked  mealy  potato  served  with  butter  or  mashed  with  cream.  Other 
foods  as  before. 

Ninth  Day. — A  little  broiled  fresh  fish  for  breakfast.  Beefsteak 
at  dinner.  Rice,  macaroni,  eggs.  Sago,  rice,  or  milk  pudding.  A 
baked  apple. 

Tenth  Day. — Mush  and  milk.  A  squab  or  breast  of  partridge  or 
roast  chicken.     Other  foods  as  before. 

For  the  next  four  or  five  days  the  patient  may  select  articles  from 
the  menu  of  the  previous  days,  so  that  three  good  meals  a  day  are 
taken,  besides  three  or  four  glasses  of  milk  between  meals. 

It  is  often  desirable  to  give  a  little  alcoholic  stimulant,  especially 
if  there  is  much  difference  in  the  frequency  of  the  pulse  between 
lying  and  sitting  or  standing,  or  if  the  pulse  rate  is  very  slow,  say 
56,  as  it  sometimes  is.  A  glass  of  sherry  or  of  good  sound  Bur- 
gundy or  a  tumbler  of  ale  may  be  drunk,  but  with  meals  only. 

Von  Ziemssen's  daily  diet  for  convalescent  typhoid-fever  patients 
is  as  follows : 

First  Breakfast. — Tea,  biscuit,  one  soft-cooked  ^ZZ- 

Second  Breakfast. — Three  and  a  half  ounces  (one  hundred  grammes) 
of  finely  minced  raw  ham  with  wheat-bread  crumbs. 

Noon. — Five  and  a  quarter  ounces  (one  hundred  and  fifty  grammes) 
of  pigeon,  young  chicken,  or  partridge  finely  minced  in  soup.  A  few 
days  later  a  mashed  potato  is  added.  Wine  or  beer  is  permitted, 
with  tea  biscuit  or  plain  cakes. 

Supper. — Mush  and  milk,  two  soft-cooked  eggs,  and  raw  ham. 
In  a  few  days  soup,  beefsteak,  mutton,  cooked  fruits,  and  beer  may 
be  given. 

Rules  for  Feeding  in  Atypical  Cases. — If  at  any  time  during 
convalescence  after  several  days  of  a  normal  temperature  it  begins 
to  rise  above  100°  or  100.5°  F-  it  is  safest  to  return  at  once  to  fluid 
diet.  If  the  temperature  falls  again  in  a  day  or  two,  convalescent 
diet  may  be  resumed.  A  sudden  rise  to  103°  F.,  or  even  higher,  last- 
ing but  a  day  or  two,  may  be  caused  only  by  constipation,  and  it  is  not 
to  be  considered  as  a  genuine  relapse,  but  until  the  cause  is  ascer- 
tained the  above  precaution  must  be  observed. 

There  is  a  class  of  patients  in  whom  the  thermometric  record  is 
likely  to  fail  as  a  guide  for  feeding  unless  it  is  correctly  interpreted. 
After  a  protracted  fever  lasting  four  or  five  weeks  the  temperature 
falls  to  about  100°  F.  and  fluctuates  daily  up  to  100.5°  or  101.5°  F. 
without  reaching  the  normal,  or  it  may  become  subnormal  and  fluc- 
tuate between  97.5°  or  98°  F.  in  the  morning,  and  101°  F.,  in  the 
afternoon.     These  patients,  in  the  absence  of  any  sequels  to  account 


TYPHOID   FEVER. 


409 


for  the  temperature  elevation,  have  a  "  starvation  fever,"  and  they 
are  usually  considerably  emaciated.  It  is  necessary  to  give  them 
solid  food  cautiously  to  bring  the  temperature  to  normal.  Some- 
times even  then  the  fever  lasts  until  they  are  allowed  to  sit  up. 

In  estimating  the  proper  time  for  giving  solid  food,  regard  must 
always  be  paid  to  the  general  severity  of  the  disease. 

Complications,  such  as  an  abscess  or  furunculosis,  may  protract  the 
fever,  although  the  intestinal  ulcers  are  completely  healed,  and  such 
patients  should  have  solid  food  in  spite  of  a  slight  elevation  of  tem- 
perature. Very  mild  cases,  in  which  the  fever  curve  subsides  in  ten 
days  or  a  fortnight,  are  deceptive  in  that  they  are  apt  to  relapse,  and 
their  fluid  diet  should  be  prolonged.  Patients  who  have  been  very 
ill  with  repeated  haemorrhage  or  hyperpyrexia  should  be  fed  with 
the  greatest  caution  during  convalescence. 

At  the  end  of  a  fortnight  of  normal  temperature,  if  the  bowels  are 
moving  regularly  and  if  there  is  no  diarrhoea,  the  patient  may  usually 
be  allowed  to  select  his  own  menu,  although  he  must  be  warned  to 
avoid  for  a  long  time  eating  food  likely  to  leave  much  insoluble 
residue,  such  as  raw  vegetables,  raw  apples,  soft-shell  crabs,  berries, 
green  corn,  old  peas,  beans,  cabbage,  tough  meats,  dried  fruits,  etc. 
He  must  be  instructed  also  not  to  excite  diarrhoea  by  eating  too 
much  fresh  fruit.  With  any  attack  of  indigestion  he  must  return  for 
a  few  days  to  a  very  simple  diet.  I  have  seen  a  second  distinct  re- 
lapse occur  on  the  twentieth  day  after  the  first,  but  such  cases  are 
fortunately  quite  exceptional. 

Typhoid  Fever  in  Children. 

Typhoid  fever  in  young  children  is  rare.  When  it  occurs  in  in- 
fants between  two  and  five  years  of  age  they  must  be  fed,  if  possible, 
exclusively  upon  milk  in  some  form,  predigested  if  necessary,  but  in 
each  case  sterilised  or  Pasteurised.  Children  usually  lake  koumiss 
well  and  thrive  upon  it. 

If  milk  is  refused,  and  emaciation  threatens  in  consequence,  some 
concession  should  be  made  in  the  rigour  of  the  diet,  but  of  course  no 
solid  food  can  be  allowed.  Beef  juice,  beef,  mutton,  or  chicken 
broths  (not  thickened),  and  beaten  egg  albumen  sweetened  and 
flavoured  with  a  few  drops  of  sherry,  may  be  substituted  for  milk  or 
alternated  with  it.  Children  take  junket  extremely  well.  When 
stimulants  are  required,  from  ten  drops  to  a  teaspoonful  of  brandy 
or  whisky,  well  diluted,  should  be  given. 

If  they  refuse  this,  a  little  Tokay,  champagne  or  wine  whey 
may  be  tried.  As  a  rule  they  need  no  alcohol  unless  they  are  very 
feeble,  or  if  complications  arise.  The  nurse  must  offer  water  freely. 
Barley  water  with  a  little  lemon  juice  is  useful  to  relieve  thirst. 

It  must  be  remembered  that  the  temperature  curve  of  enteric 


.jQ  DIET    IN    DISEASE. 

fever  in  children  is  often  very  irregular,  and  a  fall  to  near  the  nor- 
mal must  not  be  regarded  as  justifying  an  allowance  of  solid  food  at 
once,  and  no  matter  how  clamoroua  the  child  may  be  for  it,  exactly 
the  same  rigid  rules  must  be  enforced  as  in  the  case  of  adults,  and 
for  the  same  length  of  time  during  convalescence. 

TYPHUS   FEVER. 

In  general  the  dietetic  treatment  of  typhus  fever  should  be  the 
same  as  that  of  typhoid  fever,  but  as  intestinal  ulceration  is  absent 
in  the  former,  the  extreme  care  of  the  alimentary  canal  is  less  im- 
perative. The  fever  is  high  and  the  patient  is  usually  delirious, 
hence  an  exclusive  milk  diet  is  best  during  the  height  of  the  fever, 
provided  it  is  well  digested.  The  duration  of  this  fever  is  much 
shorter  than  that  of  typhoid  fever,  and  some  of  the  objections  to  a 
milk  diet  are  therefore  less  apt  to  arise.  From  four  to  six  ounces  of 
milk  may  be  given  every  two  hours. 

If  the  milk  is  not  well  assimilated  it  may  be  alternated  with  or 
supplemented  by  broths,  custard,  raw  eggs,  farinaceous  gruels,  etc. 

Abundant  water  should  be  offered,  and  the  prominent  tendency 
to  ataxic  symptoms  and  stupor  may  be  counteracted  by  strong  black 
coffee,  alcohol,  etc. 

Convalescence. — During  convalescence  the  precautions  ob- 
served in  the  treatment  of  typhoid  fever  are  not  necessary,  and 
patients  may  return  much  sooner  to  a  solid  diet;  but  some  alcoholic 
stimulant,  such  as  ale  or  porter,  will  be  needed  with  the  meals.  The 
directions  given  in  the  section  on  Diet  in  Fever  in  General  (page  387) 
may  be  observed  ;  for,  although  any  severe  fever  may  leave  the  di- 
gestive organs  somewhat  enfeebled,  there  is  no  unusual  danger  of 
this  kind  in  typhus  fever,  and  relapses  are  not  occasioned  by  dietetic 
errors. 

SMALLPOX. 

The  invasion  of  smallpox  is  usually  abrupt,  and  the  tempera- 
ture may  reach  104°  F.  on  the  first  day.  There  are  anorexia,  thirst, 
vomiting,  and  prostration,  in  addition  to  other  symptoms.  The 
fever  continues  for  three  days,  or  until  the  eruption  has  fully  devel- 
oped, after  which  it  subsides.  During  the  febrile  stage  a  light  fluid 
diet  should  be  given,  such  as  is  recommended  for  fever  in  general- 
milk,  broth,  gruel,  etc.  (page  387).  The  thirst  is  usually  consider- 
ably relieved  by  taking  cool  liquids  in  abundance,  such  as  water, 
iced  lemonade,  Seltzer  water,  etc.  If  there  is  much  eruption  in  the 
throat,  there  may  be  considerable  dysphagia.  Cracked  ice  or  cocaine 
should  be  employed  to  relieve  it. 

During  the  suppurative  stage  of  the  eruption  the  patient  requires 


SCARLET   FEVER. 


411 


an  abundant  supporting  diet,  and  as  much  milk,  eggs,  whisky,  and 
stimulating  meat  broths  should  be  prescribed  as  can  be  digested. 
The  patient  should  be  fed  at  least  once  every  two  hours,  and  must  be 
awakened  three  or  four  times  at  night  for  food.  Vomiting  is  not  to 
be  dreaded  after  the  onset  of  the  disease.  The  combined  effect  of 
the  irritation  of  so  large  a  cutaneous  eruption  and  of  the  secretion 
of  so  much  pus  from  the  pustules,  which  may  amount  to  many 
ounces,  is  exhausting  to  the  last  degree,  and  earnest  effort  must  be 
made  to  counteract  it.  This  is  especially  true  of  all  confluent  cases. 
A  dozen  eggs,  three  quarts  of  milk,  and  ten  or  twelve  or  more  ounces 
of  whisky  or  brandy,  is  not  too  much  to  order  for  an  adult.  These 
materials  may  be  given  alone  or  in  combination,  as  eggnog,  milk 
punch,  etc.  If  the  stomach  rebels  against  so  much  food,  the  rectum- 
must  be  utilised  for  part  of  the  work. 

This  supporting  treatment  should  in  all  severe  cases  be  com- 
menced early,  even  in  the  vesicular  stage  of  extensive  eruption, 
without  waiting  for  signs  of  exhaustion  which,  are  otherwise  certain 
to  follow.  If  strong  liquor  is  not  tolerated,  champagne  or  other 
wine  must  be  substituted. 

Convalescence  occupies  from  one  to  four  weeks,  according  to 
the  severity  of  the  attack.  The  diet  should  be  slowly  increased,  and 
should  comprise  abundant  animal  food,  meat,  milk,  and  eggs,  and 
alcoholic  stimulants,  such  as  ale,  porter,  or  Burgundy. 

SCARLET    FEVER. 

In  mild  cases  of  scarlet  fever  the  temperature  subsides  in  a  few 
days,  and  after  that  time,  during  the  period  of  desquamation,  special 
care  in  the  diet  is  unnecessary  unless  nephritis  is  present.  While 
the  fever  lasts  the  diet  should  be  of  fluid  character,  and  milk, 
koumiss,  soups,  broths,  and  farinaceous  gruels  of  arrowroot,  farina, 
etc.,  are  to  be  given.  In  all  cases  there  is  liability  to  renal  irritation, 
and  desquamative  nephritis  may  occur  ;  and  in  order  to  eliminate  the 
scarlatinal  poison  and  waste  products  of  the  fever  from  the  system 
as  rapidly  as  may  be,  it  is  advisable  that  the  patient  take  as  little 
nitrogenous  food  as  possible,  except  milk,  and  drink  large  quantities 
of  fluid.  Dryness  of  the  mouth  and  thirst  are  prominent  symptoms, 
and  there  is  often  difficulty  in  swallowing,  owing  to  the  inflamed 
condition  of  the  throat.  Water,  effervescing  waters  (Seltzer,  Apol- 
linaris),  barley  water,  orange  juice  in  Vichy,  and  sour  lemonade  may 
be  drunk  in  considerable  quantities. 

In  mild  cases  a  little  plain  vanilla  ice  cream  is  much  enjoyed  by 
children.  It  is  nutritious,  cooling,  and  grateful  to  the  parched 
throat. 

If  the  fever  is  high,  four  or  five  ounces  of  fluids  must  be  given 


.j2  DIET   IN    DISEASE. 

every  hour.  In  severe  cases  there  is  gastric  derangement,  and  the 
diet  must  be  restricted  to  milk  in  some  form,  as  koumiss  or  pepto- 
nised  milk.  If  nephritis  is  present,  the  milk  diet  should  be  continued, 
and  all  other  nitrogenous  food  must  be  withheld  (see  Albuminuria). 
Jaccoud  maintains  that  scarlatinal  nephritis  can  be  usually  averted 
by  keeping  the  child  upon  a  strict  milk  diet  from  the  commence- 
ment and  continuing  it  for  several  weeks. 

Convalescent  children  who  have  had  very  mild  attacks  are  often 
hungry,  but  it  is  best  to  control  their  diet  carefully  for  two  or  three 
weeks,  even  if  albuminuria  is  not  detected.  They  may  be  given  at 
first  such  articles  as  junket,  rice  pudding,  crackers,  farina,  corn- 
starch or  sago  with  cream,  milk  toast,  cream  toast,  baked  custard, 
blancmange,  wine  and  beef  jelly,  mush,  baked  apples,  stewed  prunes, 
oranges.  The  resumption  of  animal  fare  should  be  very  gradual  in 
all  cases,  and  fish,  oysters,  chicken,  or  eggs  should  be  given  before 
meat. 

MEASLES. 

The  diet  in  ordinary  cases  of  measles  does  not  require  special 
care  beyond  that  described  under  the  section  on  Diet  in  Fever  in 
General.  The  appetite  is  usually  wanting  in  the  prodromal  and 
eruptive  stages,  and  milk  with  farinaceous  gruels  answers  every 
requirement.  Thirst  is  prominent,  and  cool  water  or  lemonade  may 
be  offered,  or  orange  juice  or  unfermented  grape  juice  in  Vichy. 
Alcoholic  stimulation  is  only  needed  if  the  patient  is  very  feeble,  or 
if  severe  complications  arise.  The  resumption  of  a  solid  diet  must 
be  gradual,  but  it  may  begin  as  soon  as  the  fever  and  catarrhal 
symptoms  disappear. 

When  nursing  or  hand-fed  infants  have  measles  they  should  be 
fed  somewhat  oftener  than  usual,  and  must  be  given  less  food  at 
each  feeding.  A  child  of  eight  or  ten  months  of  age  should  be  fed 
on  diluted  milk  like  one  two  or  three  months  younger.  In  this 
manner  any  existing  catarrh  of  the  stomach  is  less  likely  to  cause 
serious  indigestion  and  vomiting.  It  is  particularly  necessary  to 
give  water,  and  half  an  ounce  should  be  offered  at  least  every  two 
hours,  or  oftener,  while  the  infant  is  awake. 

If  there  is  much  gastric  irritation  or  catarrh,  it  may  prove  best 
to  suspend  milk  feeding  for  a  day  or  two  and  substitute  meat  juice 
or  beef  or  mutton  broth. 

MUMPS. 

For  mumps  no  special  diet  is  required  beyond  the  necessity  of 
giving  fluids  or  soft  food  while  the  swelling  of  the  parotid  glands 
and  fever  last.  The  suggestions  for  the  dietetic  treatment  of  ton- 
sillitis apply  to  this  disease.     Anaemia  is  apt  to  be  extreme  during 


INFLUENZA.  4,^ 

convalescence,  and  meats  should  therefore  be  plentifully  supplied. 
Cod-liver  oil  is  very  appropriate  in  protracted  convalescence. 


WHOOPING  COUGH. 

In  whooping  cough  the  paroxysms  of  coughing  are  so  severe  as 
to  give  rise  to  vomiting,  and  in  bad  cases  they  are  excited  by  taking 
food  which  does  not  have  an  opportunity  to  become  assimilated, 
and  nutrition  may  suffer  very  seriously  in  consequen'ce,  adding  to 
the  general  exhaustion  which  accompanies  the  disease.  All  food 
must  be  made  easily  assimilable.  It  is  best  to  give  food  regularly 
in  moderate  quantity  at  each  time,  and  it  should  be  predigested 
if  necessary.  Pancreatinised  milk,  koumiss,  the  prepared  amyla-- 
ceous  foods,  cream  toast,  eggs,  junket,  chicken  broth,  malted  farina- 
ceous foods,  custard,  milk  puddings,  gruels  thiokened  with  meat 
extracts,  and  stimulants  in  the  form  of  egg  albumen  in  sherry,  egg- 
nog,  or  milk  punch,  are  recommended  for  patients  who  vomit  solid 
food. 

The  worst  cases  require  nutrient  enemata,  as  exhaustion  becomes 
critical. 

INFLUENZA. 

Symptoms. — Influenza  is  an  acute  and  moderately  infectious 
fever  of  microbic  origin  which  is  recognised  by  catarrhal  inflamma- 
tion of  the  mucous  membranes  of  the  upper  air  passages,  and  by 
symptoms  referable  to  the  nerve  centres.  In  many  cases  the  symp- 
toms are  mild  and  of  short  duration,  and  no  special  dietetic  treat- 
ment is  required  beyond  that  common  to  febricula,  but  a  large 
number  of  cases  are  accompanied  by  a  variety  of  serious  complica- 
tions or  they  present  sequelae.  In  the  majority  of  instances  the 
mucous  membranes  of  the  air  passages  are  the  principal  seat  of  the 
inflammation,  but  in  others  the  gastro-intestinal  mucous  membranes 
are  similarly  attacked,  giving  rise  to  pronounced  digestive  dis- 
orders, nausea,  vomiting,  and  diarrhoea.  The  fever,  commonly  of 
moderate  severity  (103°  to  103.5°  F.),  persists  for  three  or  four  days 
or  a  week.  There  is  usually  great  depression  of  spirits,  with  ex- 
treme malaise,  muscular  pains,  enfeebled  circulation,  and  almost  total 
loss  of  appetite.  As  an  adjunct  to  other  treatment,  absolute  rest 
in  bed  is  imperative  in  all  severe  cases,  not  only  for  the  purpose  of 
maintaining  a  uniform  temperature  and  of  protecting  the  body  from 
draughts,  but  to  guard  against  syncope  from  debilitated  heart  action. 

Dietetic  Treatment. — While  the  fever  lasts,  the  stomach  is 
usually  irritable,  and  the  diet  must  be  fluid  and  restricted.  Food 
should  be  given  in  very  small  quantities,  according  to  the  rules 
applicable  in  cases  of  extreme'debility. 


.,.  DIET   IN   DISEASE. 

414 

In  severe  cases  it  is  necessary  to  prescribe  an  exclusive  milk 
diet  for  the  first  two  or  three  days,  and  two  and  a  half  quarts 
should  be  drunk  if  possible.  Later  the  patient  may  be  given 
nourishing  beef,  mutton,  or  chicken  broths,  with  beaten  eggs  added, 
milk  toast,  custards,  eggnog,  and  milk  punch.  As  soon  as  solid  food 
can  be  eaten,  scraped-beef  sandwiches,  oysters,  tender  breast  of 
chicken,  eggs  poached  or  scrambled,  and  light  farinaceous  articles 
with  which  cream  are  appropriate. 

As  a  stimulant,  champagne  is  particularly  serviceable  in  relieving 
both  the  physical  and  mental  depression  which  is  so  characteristic  of 
nearly  all  phases  of  this  disease. 

Convalescence  is  frequently  prolonged,  and  debility,  muscular 
weakness,  irritability  of  the  heart,  and  enfeeblement  of  digestion 
are  often  present  to  a  degree  which  appears  wholly  disproportionate 
to  the  intensity  and  duration  of  the  febrile  attack.  The  diet  must 
therefore  still  be  carefully  supervised,  while  every  exertion  of  either 
body  or  mind  must  be  prohibited.  The  food  should  be  of  a  highly 
nutritious  character  and  served  in  an  appetising  and  palatable 
manner,  and  as  abundant  as  the  condition  of  the  stomach  will 
allow  (see  Convalescence  from  Typhoid  Fever,  page  406). 

Patients  with  whom  milk  usually  agrees  do  well  to  take  it  in 
quantities  amounting  to  a  quart  a  day,  in  addition  to  abundant 
solid  nitrogenous  food,  roast  beef,  beefsteak,  chicken,  eggs,  etc. 

Alkaline  waters  should  be  drunk.  If  the  appetite  flags  and 
return  of  strength  is  delayed,  tonics  and  possibly  change  of  air 
may  be  required. 

When  convalescence  is  protracted  it  is  advisable  to  continue 
alcoholic  stimulation,  and  milk  punches,  plain  whisky  and  water,  or 
a  glass  of  sound  Burgundy  may  be  given  two  or  three  times  a  day, 
as  a  tonic,  with  the  meals.  Malt  liquors  may  also  be  indicated  in 
some  cases. 

DIPHTHERIA. 

Symptoms. — Diphtheria  is  an  acute,  infectious,  and  inoculable 
disease  characterised  by  croupous  inflammation  of  mucous  mem- 
branes which  particularly  affect  the  pharynx  and  upper  air  passages. 
Clinically  the  disease  presents  fever  of  an  irregular* type,  with  great 
debility,  and  frequently  albuminuria.  Anaemia  and  rapid  loss  of 
flesh  and  strength  are  characteristic.  The  mortality  is  high,  espe- 
cially among  children,  whom  the  disease  chiefly  attacks,  and 
death  may  result  from  toxaemia,  sudden  heart  failure,  obstruction 
to  the  entrance  of  air  caused  by  accumulation  of  the  diphtheritic 
membrane,  the  extension  of  the  inflammation  down  the  air  passages, 
or  exhaustion  from  inability  to  swallow  food.  Recovery  is  uniformly 
slow,  and  may  be  still  further  retarded  by  paralysis  or  other  sequelae. 


DIPHTHERIA. 


415 


Owing  to  the  extent  to  which  the  throat  is  involved,  with  conse- 
quent difficulty  in  swallowing,  and  to  the  general  weakness  and 
prostration,  there  are  few  diseases  in  which  greater  care  in  regard  to 
dietetic  treatment  becomes  imperative.  There  is  anorexia,  and  the 
sense  of  taste  is  lost ;  nausea  is  frequently  present  as  well  as  consti- 
pation. The  cervical  lymphatic  glands  are  more  or  less  swollen  and 
give  rise  to  pain  or  soreness  on  opening  the  mouth.  Albumin  may 
appear  in  the  urine  as  early  as  the  second  day. 

Dietetic  Treatment. — "  Alimentation  occupies  the  first  place 
in  the  general  treatment  "  (Trousseau).  Throughout  the  active 
stage  of  the  disease  while  the  fever  lasts,  there  is  difficulty  in  swal- 
lowing. All  food  must  be  given  in  fluid  form,  of  which  milk  is  the 
best,  or  if,  as  sometimes  happens,  semisolid  material  is  more  easily 
swallowed,  the  food  must  be  thickened  with  cream,  gelatin,  eggs, 
or  farinaceous  articles  ;  or  beef  meal,  Mellin's  food,  malted  milk, 
etc.,  may  be  added  for  this  purpose  to  other  foods.  The  diet  should 
consist  chiefly  of  nutritious  beef  or  chicken  broth  and  beef  tea, 
egg  albumen,  eggnog,  milk,  and  milk  punch.  Plain  vanilla  ice 
cream  is  nutritious,  and  if  not  too  sweet  it  is  well  borne,  and 
is  frequently  very  grateful  to  the  inflamed  throat.  Simple  fari- 
naceous foods,  such  as  arrowroot,  thoroughly  cooked  rice,  soft 
cream  toast,  and  gruels,  may  be  taken.  Continued  disgust  for 
food  is  a  very  bad  prognostic  sign,  and  every  effort  must  be  made 
to  counteract  it  by  offering  variety.  When  the  child  is  unable  to 
swallow  on  account  of  pain  or  accumulation  of  membrane  in  the 
throat,  forced  feeding  with  a  nasal  or  stomach  tube  may  be  better 
than  reliance  upon  nutrient  enemata. 

Alcoholic  stimulation  is  usually  required  early  in  the  disease,  and 
it  should  be  given  without  stint  if  the  pulse  is  feeble  and  heart 
failure  seems  imminent.  A  child  of  three  or  four  years  should 
have  as  much  as  two  or  three  ounces  of  brandy  or  whisky  a  day, 
and  in  bad  cases  even  ten  ounces  or  more  can  be  given.  It  may 
make  the  child  dull  and  stupid,  but  it  is  the  only  way  to  combat 
severe  sepsis.  If  the  liquor,  well  diluted,  disagrees  with  the  stomach, 
it  should  be  administered  by  rectum,  or  claret,  sherry,  or  champagne 
may  be  substituted.  Nourishment  must  be  given  regularly  at  least 
every  two  hours  by  day  and  every  three  hours  by  night,  in  small 
quantities  at  a  time. 

The  digestive  ferments  papain,  or  papayotin,  and  trypsin  have 
some  solvent  action  upon  diphtheritic  membranes,  for  they  act  in 
the  medium  of  alkaline  saliva.  They  have  been  found  of  practical 
benefit  in  many  cases  when  used  in  a  spray,  to  dissolve  away  the 
membrane  as  fast  as  it  reforms. 


39 


4i6 


DIET   IN   DISEASE. 


Intubation  and  Tracheotomy. 


Intubation  of  the  larynx  is  a  method  devised  in  1880  by  O'Dwyer, 
of  New  York,  and  consists  of  the  insertion  of  a  small  gold-plated 
tube  between  the  vocal  cords,  which  is  left  in  situ,  so  that  air  can 
pass  freely  in  and  out,  the  channel  previously  blocked  by  false 
membrane  being  kept  open  by  the  tube.  The  tube  is  adjusted  to 
fit  closely  between  the  vocal  cords,  and  is  inserted  by  an  ingenious 
holder,  which  releases  it  when  in  position.  A  similar  instrument  is 
employed  for  its  removal  for  the  purpose  of  cleansing,  extracting 
plugs  of  membrane,  feeding,  etc.  The  advantage  of  using  this  tube 
as  compared  with  the  operation  of  tracheotomy  lies  in  the  fact 
that  it  can  be  very  readily  and  quickly  inserted  without  the  formal- 
ity of  an  operation,  which  is  so  much  dreaded  by  the  patient  or  by 
the  parents  of  the  child.  Moreover,  when  the  necessity  of  its  use 
has  passed,  it  is  easily  removed,  and  there  is  no  wound  left  to  heal 
or  to  become  infected  by  the  diphtheritic  inflammation.  By  those 
skilled  in  the  use  of  the  instrument  it  can  be  removed  at  any  time 
and  reinserted,  and  the  tube  is  believed  to  irritate  the  throat  less 
than  a  tracheotomy  tube.  There  are,  however,  some  disadvantages 
attending  the  use  of  this  tube,  in  addition  to  the  fact  that  it  may 
sometimes  push  the  diphtheritic  membrane  farther  down  into  the 
trachea.  It  may  be  coughed  out  by  the  child,  who  suffocates,  before 
it  can  be  replaced.  Several  cases  have  been  reported  in  which  the 
tube  has  been  coughed  up  and  then  swallowed,  and  in  which  it  has 
been  passed  into  the  oesophagus  through  carelessness.  The  latter 
mistake  is  easily  avoided  by  leaving  a  thread  tied  to  the  tube,  by 
which  it  may  be  withdrawn  if  a  false  passage  should  be  made.  The 
thread  is  fastened  about  the  ear  and  is  protected  from  the  child's 
grasp  by  adhesive  plaster.  The  child  sometimes  experiences  great 
trouble  in  swallowing  without  drawing  food  into  the  trachea.  It  is 
difficult  to  close  the  epiglottis  with  the  tube  in  position,  or  to  draw 
up  the  larynx  beneath  the  root  of  the  tongue  to  the  extent  which 
should  occur  in  normal  deglutition,  and  hence  fluid  food  particu- 
larly is  liable  to  trickle  through  the  tube  into  the  trachea,  exciting 
violent  dyspnoea  and  spasms  of  coughing.  Semisolid  food  or  solid 
food,  such  as  junket,  mush,  or  eggs,  is  more  apt  to  glide  over 
the  instrument  without  being  sucked  in  through  it  during  inspi- 
ration. Patients  usually  require  considerable  nourishment  to  sup- 
port their  strength,  so  that  the  difficulties  of  feeding  may  be 
serious. 

Very  young  infants,  who  are  dependent  upon  a  milk  diet,  can 
swallow  best  if  laid  upon  the  back  across  the  nurse's  lap  with  the 
head  downward  supported  below  her  knees.  While  in  this  position 
the  bottle  is  given  (Wharton).    Regurgitation  through  the  nose  may 


DIPHTHERIA. 


417 


occur,  but  that  is  of  little  moment  compared  with  the  accident  of 
inhaling  the  milk  through  the  tube  into  the  lungs. 

In  older  children,  when  proper  precautions  are  taken  in  regard  to 
the  position  of  the  head  in  swallowing  and  the  avoidance  of  inspira- 
tion at  the  same  time,  these  dangers  may  be  reduced  to  a  minimum, 
or  they  may  be  overcome  by  the  passage  of  an  oesophageal  tube, 
though  this  irritates  the  throat  and  may  spread  the  diphtheritic 
membrane  along  the  oesophagus.  Intelligent  children  can  learn  to 
swallow  well  with  a  little  practice  and  care  while  wearing  the  intuba- 
tion tube.  Some  even  swallow  easier  than  before  its  insertion  by 
reason  of  the  relief  of  dyspnoea,  which  always  makes  deglutition 
difficult.  In  other  cases  the  tube  may  be  temporarily  removed,  if  the 
dyspnoea  is  not  extreme,  while  the  child  takes  nourishment ;  but  this 
requires  skilled  attendance,  and,  as  the  patient  must  be  very  fre- 
quently fed,  it  possesses  great  disadvantages.  As  a  rule,  the  longer 
the  tube  remains  in  position,  the  better  the  patient  acquires  facility 
in  swallowing.  In  some  cases  it  may  be  well  to  resort  to  rectal 
alimentation  for  a  day  or  two  to  obviate  the  necessity  of  swallowing 
while  the  tube  is  worn. 

O'Dwyer  says:  "  Solids  and  semisolids,  when  there  is  an  appetite 
for  such  food,  and  when  the  patients  can  be  induced  to  take  it,  are 
swallowed  much  better  than  fluids,  and  do  not  enter  the  tube,  as  far 
as  I  am  aware  " ;  and  he  adds  that  a  bolus  of  food  tends  to  press  the 
epiglottis  down  over  the  tube,  while  fluid  tends  to  raise  it,  or  slip  in 
under  it,  although  he  has  modified  the  head  of  the  tube  by  giving  it 
a  concave  surface  to  fit  the  epiglottis. 

It  should  not  be  forgotten  with  very  young  children  that  a  failure 
to  take  food  may  be  due  to  loathing  or  nausea,  and  not  to  physical 
inability  to  swallow  with  the  tube  in  situ.  He  adds :  "  I  always  in- 
struct children  who  are  old  enough  to  understand,  to  drink  as  rapidly 
as  they  can,  and  then  cough  to  expel  any  fluid  which  may  have  en- 
tered the  tube,  instead  of  coughing  after  each  deglutition,  as  they 
usually  do."  He  discountenances  the  theory  that  food  may  enter 
the  tube  and  excite  pneumonia  by  reaching  the  deeper  portions  of 
the  lungs,  and  says  :  "  I  do  not  believe— and  there  is  no  evidence  so 
far  to  prove— that  any  of  the  fluid  entering  the  tube  ever  reaches 
the  bronchi,  for  it  is  promptly  expelled  by  coughing."  He  cites 
cases  in  support  of  this  statement,  one  being  that  of  a  woman  who 
wore  the  laryngeal  tube  for  over  ten  months  continuously,  and  en- 
joyed good  health.  He  says  that  vomited  food  enters  the  tube  even 
less  often  than  swallowed  food. 

TRACHEOTOMY. 

The  operation  of  tracheotomy  is  performed  for  obstructions  of 
various  kinds,  such  as  accumulation  of  diphtheritic  membrane  in  the 


4i8 


DIET   IN   DISEASE. 


larynx,  oedema  of  the  glottis,  etc.  The  conditions  which  require  this 
procedure  are  usually  among  those  which  interfere  to  a  greater  or 
less  extent  with  swallowing,  although  the  presence  of  the  tracheoto- 
my tube  in  the  trachea  is  well  borne  and  does  not  necessarily  conflict 
with  deglutition  in  any  manner.  No  special  precautions  in  feeding 
are  necessitated  by  the  presence  of  the  tube,  as  in  the  case  of  intu- 
bation. 

POST-DlPHTHERITIC    PARALYSIS. 

In  post-diphtheritic  paralysis  the  soft  palate  is  oftenest  affected, 
but  the  muscles  of  the  tongue  and  pharynx,  or  even  the  oesophagus, 
may  also  be  involved,  in  which  case  deglutition  is  hindered  and  the 
patient  must  be  fed  through  a  catheter  or  stomach  tube  (see  Gav- 
age)  or  by  enemata  (see  Food  Enemata). 

The  recent  phenomenal  success  of  antitoxine  inoculations  in  re- 
ducing the  mortality  of  diphtheria  to  less  than  one  third  of  its  former 
degree  offer  the  consolation  that  sequelae  of  this  nature  may  soon 
belong  only  to  the  past,  and  that  both  intubation  and  tracheotomy 
may  seldom  if  ever  be  required  in  the  future  for  this  disease. 


CEREBRO-SPINAL  MENINGITIS. 

Symptoms. — Cerebro-spinal  meningitis  is  an  infectious  disease 
of  microbic  origin,  in  which  the  chief  lesions  are  an  inflammation  of 
the  meninges  of  the  brain  and  spinal  cord.  This  inflammation  of 
the  membranous  coverings  of  the  nervous  system  results  in  the  pro- 
duction of  a  variety  of  symptoms,  including  fever,  disturbances  of 
the  nervous  and  muscular  systems,  nausea,  vomiting,  and  constipa- 
tion. The  symptoms  vary  greatly  in  severity  and  duration,  lasting 
from  a  few  days  to  several  months.  In  mild  cases  convalescence  is 
established  at  the  end  of  a  week,  but  in  severe  and  protracted  cases 
the  nervous  symptoms  increase  in  severity.  The  stage  of  excite- 
ment and  irritation  of  the  nerves  with  active  delirium  is  succeeded 
by  profound  prostration  and  coma,  with  progressive  emaciation,  a 
variable  temperature,  and  paralysis  of  the  sphincters,  with  involun- 
tary evacuations.  Such  cases  as  a  rule  prove  fatal,  but  they  are  not 
necessarily  hopeless,  and  recovery  may  occur  at  any  time.  Much, 
therefore,  depends  upon  the  careful  nourishment  of  the  patient,  and 
every  effort  should  be  directed  towards  maintaining  strength  and 
promoting  nutrition. 

Dietetic  Treatment. — In  mild  cases  a  liquid  diet  of  milk,  broth, 
meat,  and  egg  albumen,  with,  perhaps,  a  little  toast  or  crackers,  may 
be  given  while  acute  symptoms  last.  In  protracted  severe  cases,  and 
especially  where. convulsions,  delirium,  and  coma  are  present,  the  pa- 
tients must  be  fed  with  great  care,  and  all  nourishment  must  be  given 


ERYSIPELAS. 


419 


in  frequent  small  doses  and  in  an  easily  assimilable  form.  Huebner 
sometimes  employs  forced  feeding  with  the  stomach  tube.  Pancre- 
atinised  meat  broth,  pancreatinised  milk,  albumoses,  and  beef  juice 
must  be  ordered,  if  necessary,  every  fifteen  minutes.  Brandy  or 
whisky  is  required  when  hyperaemia  is  succeeded  by  exhaustion.  If 
given  too  early,  alcohol  may  increase  the  delirium.  In  extremely 
feeble  patients  such  fluids  must  be  administered  in  teaspoonful  doses, 
or  even  in  smaller  quantities,  with  a  medicine  dropper,  by  which  they 
are  passed  between  the  closed  teeth.  It  will  be  also  advisable  to 
employ  rectal  alimentation.  There  is  seldom  any  lesion  of  the  ali- 
mentary canal  present,  and  consequently  in  those  cases  in  which 
larger  quantities  of  fluid  nourishment,  or  even  solid  food,  can  be 
taken  there  is  no  objection.  If  the  patient  is  able  to  eat  and  swal- 
low properly,  milk  toast,  scraped  beef,  eggs,  custard,  wine  jelly,  farina, 
Bavarian  cream,  blancmange,  etc.,  are  indicated.  Water  may  be 
given  ad  libitum  to  relieve  the  thirst,  which  is  often  severe. 

Convalescence  will  be  promoted  by  giving  abundance  of  food. 
Five  or  six  meals  a  day  may  be  taken.  The  appetite  is  frequently 
good  from  the  commencement  of  convalescence.  Beefsteak,  chops, 
roast  beef,  mutton,  or  chicken,  bread  and  butter,  oatmeal,  porridge, 
hominy,  and  rice  with  cream,  may  be  allowed  as  soon  as  the  patient's 
digestion  admits.  A  milk  punch,  or  glass  of  claret  should  be  or- 
dered three  times  a  day. 

ERYSIPELAS. 

Symptoms. — Erysipelas  is  an  infectious  disease  caused  by  a 
specific  micrococcus,  and  characterised  by  high  fever  and  intense 
local  inflammation  of  the  skin  and  contiguous  mucous  membrane. 
There  is  usually  more  or  less  prostration  and  enfeeblement  of  the 
heart  and  circulation. 

Dietetic  Treatment. — The  indications  for  dietetic  treatment 
are  to  support  the  strength  by  stimulants  and  nutritious  foods,  which 
must  be  adapted  for  easy  digestion.  When  the  temperature  is  high, 
and  nausea  and  vomiting  exist,  nourishment  should  be  taken  in 
small  quantities— an  ounce  or  two  at  a  time  every  hour.  In  ordinary 
cases,  pancreatinised  milk,  beef  peptonoids  or  albumoses  and  beef 
juice,  eggnog,  milk  punch,  and  farinaceous  gruels  are  recommended. 
Alcohol  is  needed  and  it  is  well  tolerated,  for  it  seems  to  be  con- 
sumed in  the  system  without  intoxicating  eff'ects.  From  eighteen  to 
twenty  ounces  of  brandy  or  whisky  may  be  given  in  twenty-four 
hours.  In  extreme  cases  an  ounce  an  hour  may  be  taken,  or  if  allow- 
ance is  made  for  sleep  the  individual  doses  may  be  increased.  The 
liquor  should  be  diluted  with  plain  water,  or  with  Vichy  or  carbonic 
water,  or  soda  water.     Aged  or  debilitated  persons  and  young  chil- 


.20  I^IET    IN    DISEASE. 

dren  especially  need  vigorous  alcoholic  stimulation.  After  the  local 
inflammation  subsides  the  period  of  convalescence  requires  a  very 
nutritious  diet,  and  fluids  may  gradually  be  replaced  by  beef,  soft- 
cooked  eggs,  toast,  bread  and  butter,  and  light  farinaceous  foods 
with  cream. 

If  the  disease  invades  the  pharynx,  an  exclusive  milk  diet  is 
necessary,  and  alcoholic  stimulants  as  well  as  medicines,  except  those 
designed  for  local  treatment,  should  be  given  J>er  rectum  to  avoid  in- 
creasing the  local  irritation. 

Heuter  favours  the  drinking  of  large  quantities  of  hot  tea  to  in- 
duce perspiration,  but  it  is  doubtful  whether  this  in  any  way  affects 
the  cutaneous  lesion. 

CHOLERA. 

Dietetic  Prophylaxis. — Cholera  is  a  zymotic  disease,  the  germs 
of  which  can  only  enter  the  system  by  the  mouth,  and  they  are 
spread  chiefly  through  the  agency  of  contaminated  water  used  for 
drinking  or  washing  purposes.  All  raw  foods  and  cooking  utensils 
washed  in  such  water  are  liable  to  become  infected. 

No  raw  food  or  drink  of  any  kind  whatsoever  should  be  taken. 
In  many  cities  it  is  customary  for  the  local  health  boards  to  pro- 
hibit the  sale  of  raw  fruits  while  a  cholera  epidemic  is  in  progress. 
It  is  a  standard  rule  to  boil  everything. 

Tea,  coffee,  chocolate,  and  cocoa  should  be  made  only  with  water 
previously  sterilised  by  boiling.  Sterilised  water  only  should  be 
used  for  cleansing  the  teeth.  Water  should  not  be  cooled  by  direct 
contact  with  ice,  or  the  latter  should  be  newly  made  from  distilled 
water.  No  beer,  ale,  soda  water,  or  artificial  mineral  waters  should 
be  used  if  there  is  any  chance  of  contaminated  river  or  well  water 
having  entered  into  their  manufacture.  Milk  may  become  infected 
from  washing  the  milk  cans  in  impure  water. 

Acid  beverages  should  be  freely  drunk,  for  the  cholera  germs  do 
not  thrive  in  acid  media,  and  if  accidentally  introduced  into  the 
stomach  they  may  perish  there  if  the  gastric  contents  always  have  an 
acid  reaction.  Sour  lemonade  made  with  ten  or  fifteen  drops  of  dilute 
sulphuric  acid  has  an  excellent  reputation  as  a  prophylactic  against 
cholera.  Vinegar,  sour  pickles,  or  lime  juice  may  be  taken  for  the 
same  purpose. 

Indigestion,  perhaps  because  it  promotes  alkaline  fermentation  in 
the  stomach,  favours  infection,  and  hence  during  the  prevalence  of 
an  epidemic  it  is  desirable  to  eat  only  plainly  cooked,  wholesome 
food,  and  to  avoid  all  excesses  in  eating  and  drinking.  All  foods, 
such  as  pastry,  fried  dishes,  etc.,  having  the  reputation  of  easily  dis- 
agreeing should  be  eschewed. 

During  the  prevalence  of  an  epidemic  of  cholera  it  is  highly  im- 


CHOLERA.  ^21 

portant  to  avoid  eating  anything  likely  to  produce  diarrhoea,  and  all 
indigestible  substances,  such  as  meat,  eggs,  fish,  or  milk  not  strictly 
fresh,  unripe  or  overripe  fruit  and  vegetables,  must  be  absolutely 
forbidden. 

Symptoms.— The  symptoms  of  cholera  are  usually  divided  into 
four  typical  periods,  which  are  those  of — 

1.  The  premonitory  diarrhoea. 

2.  The  period  of  profuse  serous  diarrhoea. 

3.  The  algid  stage,  or  that  of  collapse  or  asphy.xia. 

4.  The  reactionary  stage. 

The  dietetic  treatment  varies  with  each  of  these  stages  of  the 
disease.  It  is  imperative  that  the  patient  be  kept  absolutely  quiet 
in  bed  throughout  all  the  active  phase  of  the  disease. 

First  Period. — There  is  alkaline  watery  diarrhoea  with  frequent 
profuse  stools,  nausea  and,  usually,  vomiting.  The  stomach  is  too 
irritable  to  retain  food,  and  broths  and  milk  only  furnish  culture 
media  for  development  of  the  cholera  bacilli  and  production  of 
toxines. 

During  this  period  only  light  fluid  food  in  very  small  quantity 
should  be  eaten.  Nothing  can  be  worse  than  overeating.  Whey, 
gruels,  bouillon,  or  pancreatinised  milk  only  are  permissible. 

The  contents  of  the  stomach  should  still  be  kept  acid,  and  sour 
lemonade,  lime  juice,  dilute  acid  phosphates,  dilute  vinegar,  and 
dilute  hydrochloric  acid,  twenty  or  thirty  drops  in  a  half  tumblerful 
of  water,  or  diluted  aromatic  sulphuric  acid  in  similar  dosage,  are  to 
be  swallowed  from  time  to  time.  The  acids  should  be  given  through 
a  glass  tube  to  spare  the  teeth. 

Hyperacidity  of  the  stomach  artificially  produced,  favours  the 
passage  of  a  portion  of  the  acid  stomach  contents  into  the  small 
intestine,  so  that  its  normal  alkalinity  is,  to  some  extent,  neutralised. 
The  duodenum  indeed  may  temporarily  acquire  an  acid  reaction, 
which  is  inimical  to  the  development  of  cholera  germs. 

Second  Period. — The  stools  become  more  frequent  and  serous. 
They  are  almost  continuous,  and  enormous  quantities  of  fluid  are 
rapidly  drained  from  the  system,  in  which  whitish  flakes  of  desqua- 
mated intestinal  epithelium  are  suspended.  Sometimes  they  contain 
blood.  As  much  as  two  quarts  of  fluid  may  be  discharged  in  a  single 
evacuation.  Nausea  and  epigastric  distress  occur  with  projectile 
vomiting  of  fluid,  which  exceeds  in  quantity  that  which  is  drunk. 
Intense  abdominal  cramps  follow  and  extend  down  the  legs.  The 
patient  rapidly  emaciates,  and  the  feebleness  and  prostration  are 
extreme.  There  is  a  cold  clammy  perspiration,  and  in  a  few  hours 
the  victim  passes  into  collapse.  Active  efforts  must  be  made  to 
stop  the  vomiting  and  diarrhoea.  The  abdomen  must  be  incased  in 
flannel,  and  turpentine  stupes  are  of  service  if  the  cramps  are  severe. 


^22  I>IET    IN   DISEASE. 

A  mustard  paste  may  be  placed  over  the  epigastrium,  and  a  hypo- 
dermic injection  of  morphine  is  required ;  cocaine  may  be  given 
internally.  Cracked  ice,  cold  lime  water,  iced  champagne  and  car- 
bonic-acid water,  iced  fresh  lime  juice  in  Vichy,  weak  cold  brandy 
and  Seltzer,  or  plain  soda — are  all  good  remedies  which  should  be 
offered  in  very  small  doses  every  five  or  ten  minutes.  Strong  black 
coffee  may  be  tried.  The  thirst  may  be  assuaged  by  dilute  hydro- 
chloric acid  or  lemon  juice  in  water.  A  little  fluid  held  in  the 
mouth  for  a  few  minutes  sometimes  affords  more  relief  of  this  symp- 
tom than  larger  quantities  swallowed.  It  is  worse  than  useless  to 
attempt  to  give  even  predigested  milk  while  the  vomiting  and  diar- 
rhoea continue. 

Third  Period. — In  both  the  second  stage  and  in  the  third 
stage  of  collapse  the  best  results  are  obtained  by  the  new  method  of 
hypodermoclysis — that  is,  of  hypodermic  injections  into  the  thighs 
and  sides  of  the  abdominal  wall  of  large  quantities  of  normal  salt 
solution  made  by  dissolving  50  grains  (a  scant  teaspoonful)  of  salt 
to  the  pint  of  boiled  water.  The  injections  are  given  at  the  tem- 
perature of  the  blood,  and  the  entire  quantity  may  be  used  in  the 
course  of  half  an  hour.  The  salt  solution  replaces  to  some  extent 
the  fluid  drained  by  the  serous  diarrhoea  and  emesis,  restores  the 
blood  pressure  and  equilibrium  of  the  circulation,  and  almost  im- 
mediately relieves  the  thirst. 

Fourth  Period. — If  vomiting  ceases  and  the  symptoms  of  col- 
lapse abate,  a  little  fluid  nourishment  must  be  very  slowly  and 
cautiously  tried.  A  teaspoonful  or  two  of  pancreatinised  milk, 
koumiss,  Liebig's  or  Valentine's  meat  extract,  or  fresh  beef  juice 
is  first  given.  If  this  is  retained,  the  dose  is  to  be  repeated  and  con- 
tinued by  increasing  the  quantity  and  diminishing  the  frequency  of 
administration  as  the  patient  improves.  The  stomach  remains  feeble 
and  irritable  for  many  days,  and  for  a  week  or  two  it  may  be  neces- 
sary to  limit  the  diet  to  predigested  milk,  beef  albumoses,  nutritious 
broths,  egg  albumen  in  diluted  brandy,  and  champagne.  The  further 
dietetic  treatment  may  be  conducted  in  the  manner  of  that  of  the 
convalescence  of  typhoid  fever  (page  406). 

YELLOW  FEVER. 

Symptoms. — Yellow  fever  is  an  acute,  infectious  disease  charac- 
terised by  a  sharp  febrile  paroxysm,  gastric  haemorrhage,  jaundice 
and  suppression  of  urine.  The  nature  of  the  symptoms  is  exceed- 
ingly acute  and  intense.  In  those  patients  who  die  very  soon  after 
the  invasion  of  the  disease  no  definite  lesions  are  found.  In  other 
cases  hyperaemia,  and  extravasation,  with  visceral  degeneration  are 
noted.     These  important  changes  are  found  in  the  liver  and  gastro- 


YELLOW   FEVER.  ^23 

intestinal  mucous  membrane,  and  during  the  active  progress  of  the 
infection  digestion  becomes  almost  impossible.  The  liver  presents 
the  lesions  of  parenchymatous  hepatitis.  The  hepatic  cells  here  and 
there  are  filled  with  granular  material  and  oil  globules.  Many  of 
them  are  distended  or  fused  with  indistinct  or  absent  nuclei.  The 
small  bile  ducts  are  filled  with  degenerated  epithelium,  and  the  func- 
tional activity  of  the  liver  is  therefore  almost  completely  suspended. 
The  whole  alimentary  canal  presents  the  picture  of  acute  catarrh, 
but  the  stomach  particularly  is  softened,  swollen,  and  ecchymotic, 
and  it  may  be  eroded. 

The  disease  presents  three  different  stages,  the  dietetic  treatment 
of  each  of  which  is  important,  and  it  will  therefore  be  necessary  to 
briefly  describe  them.     These  stages  are  : 

1.  The  cold  period,  followed  by  febrile  reaction. 

2.  Remission  or  "  stage  of  calm." 

3.  Second  exacerbation,  a  uraemic  condition  or  else  collapse. 
The  first  stage  begins  with  almost  immediate  vomiting  and  great 

prostration.  The  ejecta  consist  first  of  mucus,  then  bile  in  increas- 
ing amount,  and  finally,  if  the  retching  continues  and  muscular 
straining  is  severe,  the  irritability  of  the  stomach  in  this  period  be- 
comes greater  than  in  almost  any  other  disease.  The  slightest  pres- 
sure over  the  epigastrium  excites  projectile  vomiting.  Constipation 
is  present  from  the  inability  to  retain  fluids;  the  mouth  becomes  dry 
and  the  gums  sore  and  swollen,  and  thirst  is  extreme.  The  urine  is 
much  diminished  in  volume  as  the  changes  in  the  liver  progress,  and 
the  bile  ducts  are  blocked  with  degenerated  epithelium  ;  the  bile 
enters  the  blood,  and  the  skin  and  conjunctivae  become  decidedly 
jaundiced. 

After  several  days — usually  four  or  five — these  symptoms  sub- 
side and  the  second  period  is  reached.  The  duration  of  this  period 
seldom  exceeds  two  days,  and  it  may  continue  but  a  few  hours.  It 
is  a  condition  of  calm,  in  which  all  symptoms  are  abated  ;  the  fever, 
which  may  previously  have  existed,  subsides  and  the  gastric  irrita- 
tion is  lessened. 

The  third  period  promptly  succeeds  the  second,  and  in  it  the 
symptoms  of  the  first  period  return  with  renewed  severity,  and  in 
addition  a  condition  of  uraemia  develops.  Haemorrhage  of  the  stom- 
ach, known  as  "black  vomit,"  is  present  in  about  one  third  of  the 
fatal  cases.  The  vomited  material  ejected  during  the  course  of  the 
disease  consists,  first,  of  whatever  food  the  stomach  may  contain, 
then  of  bile-tinged  mucus,  and  finally  of  a  deep  brown  or  black 
grumous  acid  semifluid  substance  resembling  coffee  grounds,  which 
consists  of  red  blood-corpuscles,  pigment  granules,  degenerated  mu- 
cus, epithelial  cells,  leucocytes,  fatty  matter,  and  serous  fluid.  The 
action  of  the  gastric  juice  upon  the   extravasated   blood  pigment 


424  I*IET   IN   DISEASE. 

turns  it  dark  brown  or  black.  The  quantity  of  this  fluid  may  reach 
several  pints.  It  is  acrid  and  irritating  to  the  fauces  and  mouth. 
The  blood  from  the  passively  congested  surface  oozes  freely  from 
the  capillary  walls  of  the  gastric  mucous  membrane.  The  intestinal 
mucous  membrane  may  be  similarly  affected,  in  which  case  the  stools 
are  black  and  diarrhoeal.  The  urine  becomes  very  scanty,  and  may 
be  entirely  suppressed.     There  is  hsematuria. 

Should  recovery  result,  the  jaundice  continues  for  some  days,  but 
the  other  symptoms  subside  gradually  and  convalescence  is  always 
slow  and  may  be  retarded  by  various  complications,  among  the  most 
serious  of  which  are  an  exceedingly  irritable  stomach  and  intestine. 
Errors  in  diet  have  been  known  to  cause  fatal  haemorrhage  from  the 
stomach  as  long  as  a  fortnight  or  three  weeks  after  beginning  con- 
valescence. The  heart  action  after  such  a  severe  ordeal  is  always 
feeble,  and  reparative  and  nutritive  processes  advance  slowly.  Irri- 
tability of  the  stomach  may  even  persist  for  several  months  after  the 
subsidence  of  all  other  symptoms.  This  brief  account  of  the  more 
important  features  of  the  disease  emphasises  the  necessity  for  most 
careful  dietetic  management. 

Treatment  of  the  First  Period. — The  patient  must  be  im- 
mediately put  to  bed  and  kept  absolutely  free  from  excitement. 
Rest  in  a  recumbent  position  must  be  carefully  enjoined,  and  the 
patient  must  not  be  allowed  to  even  raise  the  head  to  drink. 
Medicine  and  fluids  must  be  given  through  a  tube  or  with  a  tea- 
spoon. If  the  patient  is  seen  promptly,  and  there  is  a  probability  of 
undigested  food  being  present  in  the  stomach,  that  organ  should  be 
unloaded  by  an  emetic,  and  as  little  medicine  as  possible  should  be 
ordered.  If  constipation  is  present  the  bowels  should  be  emptied  by 
a  purgative  enema.  It  is  generally  considered  that  profuse  perspira- 
tion is  an  advantage.  This  object  can  be  accomplished  by  covering 
the  patient  with  blankets  and  giving  a  hot  lemonade  or  hot  toddy, 
such  as  hot  whisky  and  water. 

As  the  vomiting  becomes  more  and  more  severe,  efforts  may  be 
made  to  relieve  it,  but  if  all  measures  fail,  it  will  be  best  to  let  the 
stomach  have  absolute  rest,  which  is  secured  by  hypodermic  injec- 
tions of  morphine,  mustard  paste  over  the  epigastrum,  and  the  use 
of  the  rectum  for  all  medication.  Among  the  various  means  at  com- 
mand for  the  relief  of  the  vomiting  are  cracked  ice,  light  acidulated 
and  effervescing  draughts,  such  as  acid  lemonade,  Vichy,  Seltzer,  or 
carbonic  water,  strong  coffee,  plain  lime  water  in  frequent  half-ounce 
doses  given  cold,  besides  cocaine,  diluted  hydrocyanic  acid,  cerium 
oxalate,  etc.  Iced  champagne,  very  dry  Mumm  or  Pommery  sec,  or 
acid  lemonade  with  bitartrate  of  potassium,  will  sometimes  be  re- 
tained. With  the  supervention  of  uraemic  symptoms,  or  when  there 
is  suppression  of  urine,  there  is  urgent  need  of  getting  more  fluid 


YELLOW   FEVER.  425 

into  the  body.  The  lumbar  region  should  be  cupped  or  poulticed 
or  Covered  with  a  mustard  paste.  If  aerated  waters  are  not  toler- 
ated by  the  stomach,  three  or  four  pints  of  salt  water  should  be  in- 
jected into  the  rectum  every  two  hours,  or  it  is  suggested  that  hypo- 
dermoclysis  might  prove  of  service  after  the  manner  employed  in 
cholera  (page  422).  While  the  fever  lasts,  or  throughout  the  first 
period,  it  is  usually  best  not  to  attempt  to  give  food  at  all,  for  the 
stomach  is  almost  certain  to  reject  or  fail  to  digest  it. 

Cochran  dissents  somewhat  from  the  prevalent  practice  of  allow- 
ing no  food  during  this  stage,  and  believes  that  an  attempt  should 
be  made  to  supply  a  little  nourishment  per  os,  to  fortify  the  system 
against  the  future  drain  upon  it  which  is  certain  to  follow.  He  says: 
"  I  have  seen  infants  at  the  breast  pass  through  attacks  of  yellow 
fever  to  prompt  recovery,  throwing  up  black  vomit  frequently  and 
freely,  and  nursing  as  regularly  and  heartily  as  if  there  was  nothing 
the  matter  with  them." 

Many  cases  of  yellow  fever  occur  among  previously  healthy 
people  who  can  withstand  the  absence  of  food  for  a  day  or  two 
without  serious  loss,  provided  exhausting  symptoms  can  be  held  in 
check.  In  many  instances,  however,  prostration  and  exhaustion 
occur  with  extraordinary  rapidity,  and  in  an  hour  the  patient  may  be 
too  feeble  to  articulate  or  move.  Active  stimulation  by  the  rectum 
and  hypodermically  is  then  necessary.  For  this  purpose  whisky  is 
best.  It  should  be  obtained  pure  and  injected  hypodermically  with 
a  sterilised  syringe  in  quantities  of  one  to  three  drachms.  The 
injections  may  be  made  beneath  the  skin  on  the  outer  surface  of 
the  thigh  and  arms  in  four  or  five  places.  Two  ounces  of  whisky 
diluted  in  an  equal  part  of  water  may  be  injected /^r  rectum. 

Treatment  of  the  Second  and  Third  Periods.— During  the 
interval  of  the  second  period  abatement  of  the  fever  and  of  the 
gastric  irritation  may  admit  of  a  little  nourishment  being  taken  by 
the  stomach.  Some  patients  recover  without  passing  into  the  third 
period,  but  because  many  do  not,  extreme  caution  must  be  observed 
and  food,  if  taken  at  all,  must  be  in  very  minute  quantities.  The 
same  rules  in  regard  to  diet  and  stimulants  apply  to  the  third  period 
which  have  been  prescribed  for  the  first,  and  the  main  reliance  for 
nourishment  should  be  through  rectal  alimentation.  When  the 
paroxysm  is  over  and  the  symptoms  have  abated,  the  greatest  care 
must  still  be  exercised  in  regard  to  diet  even  if  the  patient  is  hungry, 
as  sometimes  happens.  In  the  worst  cases  no  solid  food  should  be 
permitted  for  at  least  ten  days  or  a  fortnight,  and  it  must  be  re- 
membered that  fatal  relapses  have  been  precipitated  by  not  observ- 
ing this  rule.  When  the  vomiting  and  epigastric  pain  have  ceased, 
half-a-teaspoonful  or  teaspoonful  doses  may  be  given  once  in  fifteen 
minutes   of    pancreatinised    milk,  koumiss,   Liebig's    or  Valentine's 


^g  DIET   IN   DISEASE. 

meat  extract,  iced  dry  champagne,  or  good  Rhine  wine.  If  such 
foods  are  retained,  they  may  be  followed  after  some  hours  by  a 
few  spoonfuls  of  pressed  beef  juice,  salted,  and  later  still  by  warm, 
nourishing  beef  broths,  chicken  broths,  gruels,  or  buttermilk.  Stimu- 
lating or  nutrient  enemata  should  still  be  ordered,  because  in  the 
early  stages  of  convalescence  the  stomach  will  not  tolerate  all  the 
food  which  the  impoverished  tissues  require.  Any  epigastric  ful- 
ness or  distress,  or  tympanites,  should  be  regarded  as  a  warning, 
and  food  should  be  again  withheld  until  the  difficulty  is  corrected  by 
antacids  or  antifermentatives. 

It  is  to  be  noted  that  children  usually  require  rectal  feeding  and 
stimulation  even  earlier  than  adults.  Large  doses  of  opium  given 
to  aid  the  retention  of  nutrient  or  stimulating  enemeta  should  be 
avoided  on  account  of  the  tendency  to  suppression  of  urine.  In 
mild  cases,  after  four  or  five  days,  and  in  severe  cases  after  a  fort- 
night, solid  food  may  be  occasionally  given,  commencing  with  milk, 
toast,  crackers,  junket  and  "cream  custard,  farina  and  boiled  or 
broiled  chicken,  soft-cooked  eggs,  wine  jelly,  boiled  rice,  scraped 
beef,  and  similar  nourishment. 

Fruits  and  vegetables  should  not  be  allowed  for  several  weeks. 


PYyEMIA    AND    SEPTIC>dVIIA. 

In  all  septic  conditions  the  diet  must  be  made  as  nutritious  as 
possible,  and  alcoholic  stimulation  must  be  given  with  a  free  hand, 
brandy  or  whisky  being  the  best  forms.  As  a  rule,  the  diet  must  be 
fluid,  but  in  very  chronic  cases  and  those  accompanied  by  prolonged 
local  suppuration  easily  digestible  solid  food — such  as  broiled  fish 
or  beefsteak  or  chicken,  oysters,  toast,  light  bread  and  butter,  and 
light  farinaceous  articles  with  cream — may  be  allowed.  The  general 
directions  given  in  the  article  upon  the  diet  of  fevers  and  con- 
valescence are  applicable  here,  and  as  the  patient  improves,  the 
stimulating  diet  recommended  for  some  cases  of  tuberculosis  (see 
Dietetic  Treatment  of  Tuberculosis,  page  439)  is  recommended. 


MALARIAL    FEVERS. 

Intermittent  Fevers. — The  dietetic  management  of  malarial 
fevers  consists  of  the  treatment  during  the  paroxysms  and  of 
that  between  them.  In  intermittent  fever  the  paroxysms  although 
severe,  are  comparatively  brief.  Vomiting  often  accompanies  the 
chill.  If  the  patient  is  disinclined  to  take  food  there  is  nothing  to 
be  gained  by  urging  it  upon  him,  and  the  stomach  may  be  allowed 
to  rest  for  a  day.  Otherwise  a  glass  of  milk  or  a  cup  of  broth  may 
be  given.     When  the  paroxysm  is  over,  if  the  appetite  returns,  solid 


TETANUS. 


427 


food  may  be  given  without  much  restriction.  If  a  patient  has  had 
several  attacks  at  brief  intervals  he  is  usually  both  anaemic  and  con- 
stipated, and  the  subsequent  diet  should  contain  a  liberal  proportion 
of  animal  food  to  counteract  the  former  condition,  and  of  fresh 
fruits  and  green  vegetables  for  the  latter.  Beyond  these  general 
directions  but  little  is  usually  necessary. 

Remittent  Fevers. — In  the  continued  malarial  fevers,  indiges- 
tion or  feeble  digestion  may  be  a  prominent  symptom,  requiring  a 
milk  diet  while  the  fever  is  at  its  height.  The  reader  is  referred  to 
the  article  upon  the  Treatment  of  Fever  in  General  (page  387),  which 
will  cover  the  ground  for  these  cases,  as  they  present  no  peculiarities. 

Patients  with  malarial  fever  are  very  apt  to  resort  too  freely  to 
the  whisky  bottle,  and  overstimulation  in  the  continued  fevers  is  a 
common  fault.  Only  the  severer  forms  of  Southern  and  tropical 
agues,  bilious  remittent  fever,  etc.,  require  much  alcohol.  The  die- 
tetic treatment  of  the  latter  corresponds  with  the  directions  given 
for  that  of  yellow  fever  (page  424), 


TETANUS. 

Symptoms. — Tetanus  is  an  acute  infection  caused  by  a  bacillus 
which  enters  the  body  through  an  abraded  surface,  develops  toxines 
in  the  system,  and  causes  greatly  exaggerated  irritability  of  the  cen- 
tral nervous  system.  With  the  heightened  reflexes,  tetanic  contrac- 
tion of  the  voluntary  muscles  occurs,  especially  of  those  of  the  jaw, 
face,  and  the  extensors  of  the  back.  The  ordinary  reflex  action  from 
peripheral  excitation  is  so  far  intensified  that  the  slightest  pressure 
on  the  surface  of  the  body,  or  change  in  surrounding  temperature, 
or  even  a  loud  sound,  may  throw  the  patient  into  violent  convul- 
sions and  painful  tonic  spasms.  Efforts  in  swallowing  may  induce 
them.  The  muscles  of  the  jaw  are  often  set  in  a  condition  of 
rigid  contraction,  making  it  impossible  for  the  patient  to  open 
the  mouth  to  take  food,  and  forcible  efforts  to  separate  the  teeth 
excite  convulsions.  It  is  necessary  to  support  the  strength  by  every 
available  means,  for  tetanus  is  not  invariably  a  fatal  disease,  al- 
though, according  to  Gowers,  death  results  in  about  90  per  cent  of 
all  cases.  Recent  successful  inoculation  experiments  with  immu- 
nised serum  offer  the  hope  that  recovery  may  be  possible  in  a  larger 
number  of  cases  provided  the  strength  of  the  patient,  which  is  rapidly 
exhausted  by  convulsions,  can  be  maintained. 

Dietetic  Treatment. — Food  can  only  be  given  in  liquid  form, 
but  if  a  front  or  side  tooth  is  absent  a  soft-rubber  catheter  may  be 
passed  in  between  the. teeth  and  fluid  can  be  conveniently  poured 
into  the  mouth  through  it.  Milk,  egg  albumen,  eggnog,  nutritious 
beef,  mutton,  or  chicken  broths,  malted  gruels,  wine,  brandy,  and 


428 


DIET    IN    DISEASE. 


whisky  should  be  given  as  frequently  as  the  condition  of  the  patient 
will  admit.  If  possible,  from  two  to  four  ounces  should  be  adminis- 
tered every  hour.  The  spasm  does  not  affect  the  involuntary  muscles, 
so  that  food  is  swallowed  if  it  can  be  placed  far  back  in  the  pharynx. 
Alcoholic  stimulation  and  nourishment  can  also  be  given  by  the  rec- 
tum, but  this  method  is  as  apt  to  excite  convulsions  as  mouth  feed- 
ing. If  severe  convulsions  are  induced  by  every  attempt  to  feed 
the  patient,  it  becomes  necessary  to  put  him  under  primary  anaesthe- 
sia by  the  inhalation  of  chloroform,  and  then  a  tube  may  be  passed 
into  the  stomach,  through  which  twelve  or  sixteen  ounces  of  soup  or 
predigested  milk,  eggnog,  and  stimulants  may  be  poured.  By  this 
means  he  is  disturbed  much  less  often  and  larger  quantities  of  nour- 
ishment are  taken  at  one  time.  In  a  recent  case  of  tetanus  which 
came  under  my  observation,  and  in  which  tetanus  bacilli  were  found, 
the  muscular  spasms  were  intense  and  almost  continuous  for  over 
five  weeks.  The  difficulty  in  feeding  the  patient  was  extreme,  and 
emaciation  was  very  pronounced.  He  complained  incessantly  of 
thirst,  and  often  of  hunger,  but  he  was  able  to  swallow  milk  broths 
and  stimulants  given  between  the  closed  teeth  in  very  frequent 
doses,  and  his  final  recovery  was  attributable  mainly  to  persistent 
efforts  at  careful  feeding,  anaesthesia  having  been  several  times  suc- 
cessfully employed. 

RABIES. 

In  feeding  a  patient  with  rabies,  substantially  the  same  plan  is  to 
be  followed  as  that  above  described  for  tetanus.  In  some  cases, 
however,  even  in  the  early  stages,  all  efforts  to  swallow  fluid  food 
excite  violent  general  convulsions.  Osier  suggests  that  this  spasm 
may  be  lessened  by  application  of  cocaine  to  the  throat,  so  that  the 
patient  can  swallow.  Failing  this,  nutrient  enemata  must  be  relied 
upon,  but  they  also  sometimes  excite  convulsions.  In  this  case  it  is 
justifiable  to  produce  primary  anaesthesia  with  chloroform,  and  to 
seize  the  moment  of  temporary  relaxation  for  feeding. 


TUBERCULOSIS. 

Causation. — Tuberculosis  is  an  infectious  disease,  due  to  the 
presence  in  some  part  of  the  body  of  the  Bacillus  tuberculosis.  The 
disease  may  be  either  acute  or  chronic,  but  in  all  cases  fever  is  pres- 
ent whenever  there  is  an  exacerbation  of  the  symptoms.  The  latter 
are  both  local  and  general,  and  vary  with  the  particular  organ  or 
organs  affected,  but  the  lungs  constitute  by  far  the  most  frequent 
site  for  the  development  of  the  germs.  The- bacillus  produces  from 
the  tissue  or  soil  in  which  it  grows  a  toxine  or  poisonous  substance 
which  enters  the  circulation  by  absorption  and  which  modifies  nutri- 


TUBERCULOSIS. 


429 


tion,  causing  pyrexia  and  an  increased  production  of  tissue  waste, 
with  more  or  less  rapid  emaciation. 

Several  factors  combine  to  disturb  the  digestive  system.  These 
are  : 

1.  The  fever  itself. 

2.  The  impoverished  condition  of  the  blood,  which  affects  the 
quality  and  quantity  of  the  digestive  juices. 

3.  In  pulmonary  tuberculosis,  after  the  expectoration  becomes 
considerable  it  is  often  ropy  and  tenacious,  and  some  of  it  is  very 
apt  to  adhere  to  the  surface  of  the  mouth  or  pharynx,  and  be  swal- 
lowed with  the  food  or  saliva,  with  the  result  of  exciting  gastric  and 
intestinal  catarrhs,  or  possibly  of  locally  infecting  the  mucous  mem- 
brane of  the  intestine  with  the  bacilli,  which  produce  ulceration  with 
further  impairment  of  the  digestive  functions  and  of  absorption. 

The  prognosis  of  a  given  case  depends  very  largely  upon  the 
digestion. 

General  Consideration  of  Dietetic  Treatment. — Proper  diet- 
ing is  unquestionably  one  of  the  most  important  factors  in  the  pro- 
phylactic as  well  as  the  active  treatment  of  pulmonary  tuberculosis, 
and  in  prescribing  a  regimen  many  things  must  be  taken  into  con- 
sideration besides  the  mere  classification  and  selection  of  food.  The 
disease  may  be  exceedingly  protracted,  lasting  for  years,  with  in- 
tervals in  which  the  patient  enjoys  a  comparative  degree  of  health 
and  comfort,  which  temporarily  emancipate  him  from  dietetic  re- 
strictions. But  even  then  he  should  see  to  it  that  his  food  is  ample 
for  his  bodily  needs.  Malnutrition  at  any  time  may  excite  a  latent 
tubercular  process  to  renewed  activity,  and,  on  the  other  hand,  an 
increase  in  body  weight  is  accompanied  by  marked  improvement  in 
the  symptoms  of  the  disease.  • 

Since  the  disease  is  so  chronic  the  pecuniary  circumstances  of 
the  patient  must  be  considered.  By  ordering  him  to  abandon  his 
only  means  of  livelihood  or  to  undertake  a  long  and  expensive 
journey  he  may  be  so  impoverished  that  he  cannot  afford  to  procure 
the  best  food,  which  is  so  essential  both  to  repair  the  tissue  waste, 
which  sooner  or  later  is  a  prominent  feature  of  the  disease,  and  to 
supply  energy  ;  and  good  climate  is  of  little  use  unless  it  helps  him 
to  acquire  a  better  appetite  and  easier  digestion. 

The  appetite,  too,  must  be  consulted.  It  is  sometimes  better  to 
humour  whims  than  to  seek  to  combat  them,  and  inflexible  rules  can 
no  more  be  enforced  for  dieting  than  for  medication.  The  appetite 
is  often  very  poor  or  capricious,  and  the  physician's  dietetic  expe- 
dients will  be  severely  taxed  to  devise  suitable  foods  which  meet  all 
requirements.  The  patient  should  be  given  a  list  of  foods  which  he 
can  regularly  eat,  foods  to  be  avoided,  and  foods  which  he  may  have 
as  an  occasional  indulgence. 


.,Q  DIET    IN   DISEASE. 

Young  phthisical  girls  especially  are  apt  to  long  for  sweets  and 
confectionery,  and  despise  the  more  wholesome  animal  food;  in  fact, 
some  writers  regard  this  as  a  symptom  of  the  disease  in  such  cases. 
If  they  cannot  have  what  they  crave  they  will  refuse  what  they  are 
allowed,  and  much  tact  and  persuasion  is  required  to  induce  them  to 
eat  rationally. 

Since  so  much  depends  upon  sustaining  the  nutrition  and  strength 
of  tuberculous  patients,  it  is  of  the  utmost  importance  to  keep  the 
stomach  and  bowels  in  the  best  possible  condition. 

Patients  should  be  warned  never  to  swallow  their  sputum,  for 
this  always  excites  dyspepsia,  and  sooner  or  later  gastric  catarrh. 
The  occurrence  of  the  latter  is  also  favoured  by  the  habit,  which 
many  patients  acquire,  of  perpetually  taking  cough  medicines  and 
patent  "sure  cures,"  many  of  which  contain  potassium  iodide  and 
other  gastric  irritants.  In  advanced  cases  the  catarrh  may  be  a 
sequel  to  enfeebled  circulation. 

All  food  should  be  fresh  and  carefully  selected,  and  the  cooking 
should  be  as  simple  as  possible  without  monotony.  Viands  should 
be  savoury,  and  served  in  a  manner  to  tempt  the  palate. 

The  most  important  articles  of  diet  for  the  consumptive  are  the 
animal  foods,  and  milk,  beef,  and  fats  and  oils  should  form  the  essen- 
tials, rather  than  too  much  meat ;  but  in  ordinary  cases  any  variety  of 
properly  cooked  animal  food  may  be  eaten.  Starches  and  sugars  are 
allowable  in  milder  cases,  but  never  to  the  exclusion  of  nitrogenous 
aliments,  and  not  at  all  if  gastric  catarrh  exists. 

In  phthisis  there  often  seems  to  be  a  failure  to  assimilate  amyla- 
ceous and  saccharine  food,  which  is  beyond  that  which  is  explainable 
by  the  presence  of  catarrhal  conditions.  These  substances,  which  or- 
dinarily furnish  a  large  proportion  of  the  energy  of  the  body,  in 
tuberculosis  appear  to  do  so  less  readily  than  the  fats  and  proteids. 
Growing  children,  however,  require  more  carbohydrates  than  do 
adults.  Malt  is  especially  valuable  as  a  tonic  in  tuberculosis,  and 
the  diastase  aids  assimilation  of  farinaceous  foods. 

Great  diversity  exists  among  different  phthisical  patients  in  the 
power  of  assimilation  of  food,  and  even  in  individual  cases  during  the 
progress  of  the  disease. 

Bauer  says :  "  One  not  infrequently  sees  phthisical  patients  who 
consume  the  full  hospital  diet  without  any  visible  ill  effects,  although 
their  evening  temperature  oscillates  between  39°  and  40°  C.  (102°  to 
104°  F.).  With  such  patients  one  need  feel  no  anxiety  as  to  the 
choice  of  foods,  provided  their  nutritive  value  be  the  same." 

Rest  is  important  in  its  relations  to  digestion,  and  patients  should 
not  eat  when  fatigued.  Great  benefit  is  often  derived  by  lying  down 
and  quietly  resting,  even  without  sleeping,  for  half  or  three  quarters 
of  an  hour  before  dinner  and  supper.    It  is  best  to  take  the  principal 


TUBERCULOSIS. 


431 


meal  in  the  middle  of  the  day  unless  there  is  fever  at  that  time  or 
soon  after  it,  in  which  case  a  hearty  breakfast  and  a  light  lunch  will 
be  better  borne. 

If  much  hectic  fever  is  present,  it  is  desirable  to  employ  the 
intervals  when  the  temperature  is  low  for  feeding,  and  it  often  hap- 
pens that  a  hearty  meal  taken  between  7  and  10  a.  m.  may  be  better 
digested  than  at  any  other  time  of  day. 

Patients  should  avoid  eating  more  food  at  any  one  time  than  they 
can  comfortably  digest,  and  it  is  often  best  to  give  food  five  or  six 
times  in  twenty-four  hours,  to  avoid  overworking  the  stomach.  If 
the  digestion  is  feeble,  it  is  best  to  give  only  one  article  of  food  at  a 
time,  or  else  only  such  varieties  of  food  as  require  the  same  length 
of  time  for  digestion  (page  322),  and  patients  often  do  better  when 
they  eat  all  their  animal  food  at  one  meal  and  vegetable  food  at  an- 
other, having  regard  to  the  separate  action  performed  by  the  stomach 
and  intestines  upon  these  different  food  classes.  If  there  is  stomach 
catarrh  or  if  the  gastric  juice  is  feeble  the  quantity  of  fluid  taken 
with  meals  should  be  restricted  to  a  minimum,  excepting  in  very  ad- 
vanced cases,  in  which  the  diet  may  be  necessarily  entirely  fluid.  But 
half  a  pint  of  very  hot  water  may  be  taken  with  advantage  half  an 
hour  before  each  meal,  to  cleanse  and  stimulate  slightly  the  gastric 
mucous  membrane. 

Loomis  wrote:  "When  the  pressure  of  food  in  the  stomach  ex- 
cites cough,  or  when  paroxysms  of  coughing  have  induced  vomiting, 
the  ingestion  of  food  must  be  delayed  until  the  cough  ceases,  or  an 
appropriate  sedative  may  be  employed.  In  those  extreme  cases 
where  every  attempt  at  eating  excites  nausea,  vomiting,  and  spas- 
modic coughs,  excellent  results  are  attained  by  artificial  feeding 
through  the  soft  rubber  stomach  tube." 

Meats. — Raw  beef  is  extolled  by  many  physicians,  especially 
among  the  French,  as  possessing  peculiar  nutritive  and  even  cura- 
tive value  for  tuberculosis,  and  in  the  popular  mind  its  blood-red 
colour  and  scarlet  juice  seem  to  suggest  an  intimate  connection  with 
blood  formation.  It  is  true  that  blood  and  muscle  have  great  simi- 
larity of  composition.  The  red  wines  are  regarded  by  laymen  in  the 
same  light.  It  has  yet  to  be  demonstrated  that  raw  meat  possesses 
any  advantage  over  rare  steak  or  underdone  roast  beef  beyond 
the  fact  that  the  scraping  and  mincing  process  to  which  it  is  usually 
subjected  prepares  it  somewhat  better  for  solution  by  the  gastric 
juice. 

Patients  will  often  take  scraped  raw-meat  balls  contentedly  for 
several  days,  and  then  acquire  a  distaste  for  them.  This  may  be 
overcome  by  seasoning  with  a  little  aromatic  herb,  such  as  thyme, 
parsley,  or  marjoram.  Yeo  suggests  that  when  made  into  small  balls 
the  meat  may  be  covered  with  pov/dered  sugar  or  gum,  and  swallowed 
30 


DIET   IN   DISEASE. 
43- 

with  a  sip  of  wine  or  brandy,  or  the  mouth  may  be  rinsed  with  claret 
to  remove  the  after-taste. 

Both  scraped  beef  and  the  various  preparations  of  beef  powder, 
beef  meal,  etc.,  are  useful  to  re-enforce  broths,  hot  milk,  milk  punch, 
or  light  soups  of  vermicelli,  tapioca,  etc.  According  to  Prof.  Chit- 
tenden (Trans.  Philadelphia  County  Med.  Soc,  1891),  the  nutritive 
value  of  lean  beef  being  placed  at  100,  that  of  beef  peptonoids  is  140 
and  that  of  Mosquera's  beef  meal  is  400.  If  preferred,  from  one  to 
five  ounces  of  beef  meal  may  be  eaten  daily,  spread  like  jam  upon 
bread  and  butter.  Insomnia  may  be  often  prevented  by  taking  on 
retiring  a  cup  of  hot  bouillon,  clam  broth,  or  gruel,  with  a  cracker  or 

two. 

Beef  juice,  extracted  by  a  small  meat  press,  may  be  ordered  two 
or  three  times  a  day.  It  may  be  seasoned  and  drunk  Hke  bouillon,  or 
eaten  as  a  luncheon  upon  dry  toast,  crackers,  or  boiled  rice. 

H.  P.  Loomis  gives  the  following  useful  details  in  regard  to  the 
preparation  of  this  important  food :  "  To  obtain  from  the  meat  the 
maximum  amount  of  juice,  a  meat  squeezer  is  absolutely  essential. 
There  are  a  number  of  good  ones  in  the  market,  which  range  in  price 
from  one  to  three  dollars.  The  best  kind  of  meat  from  which  to 
squeeze  the  juice  is  a  thick  round  steak  free  from  fat.  This  should 
be  seasoned  with  pepper  and  salt,  broiled  over  a  brisk  fire,  then  cut 
in  pieces  two  inches  square,  and  then  put  into  the  meat  squeezer. 
About  eight  ounces  of  juice  can  be  obtained  from  each  pound  of 
meat.  No  heat  can  be  applied  to  the  juice,  as  the  albumin  would 
be  at  once  coagulated  and  the  juice  rendered  worse  than  useless. 
If  the  juice  becomes  cold  and  it  is  advisable  to  heat  it,  this  can  be 
best  accomplished  by  placing  the  cup  in  hot  water.  It  is  necessary 
to  go  fully  into  the  preparation  of  the  beef  juice,  because  of  its  im- 
portance as  one  of  the  most  essential  items  in  the  diet  of  phthisis. 
Freshly  squeezed  beef  juice  is  the  best  of  the  artificial  preparations 
of  meat  known,  and  the  trouble  of  preparing  it  is  well  repaid  by  the 
marked  improvement  in  the  patient." 

It  is  often  desirable  to  give  dilute  hydrochloric  acid  and  a  little 
pepsin  after  the  ingestion  of  meat  or  other  animal  food  unless  it  has 
been  predigested. 

Eggs. — Eggs  are  not  well  borne  if  there  is  dyspepsia  or  decided 
gastric  catarrh.  Otherwise  they  are  nutritious  and  wholesome. 
They  may  be  given  raw,  beaten,  or  very  lightly  cooked  in  hot  water, 
but  never  hard  boiled.  They  may  also  be  eaten  scrambled  or  as  an 
omelet  if  lightly  made. 

Egg  albumen  will  often  be  well  digested  when  the  yolk  proves 
too  rich. 

"  A  raw  egg  sucked  from  the  shell  will  often  relieve  an  irritable 
condition  of  the  larynx  "  (H.  P.  Loomis). 


TUBERCULOSIS.  ^jj 

Cereals. — Cereals  may  be  used  in  the  early  stage  of  the  disease, 
before  the  alimentary  canal  is  much  disturbed,  and  such  foods  as 
corn  mush,  farina,  oatmeal,  wheaten  grits,  or  germea  may  be  allowed 
with  cream.  If  cream  and  sugar  disagree,  they  may  be  eaten  with 
lemon  juice. 

Fruits. — The  succulent  fruits  are  well  borne  in  mild  cases,  and 
are  very  wholesome  and  nutritious.  Baked  and  stewed  apples  may 
be  given,  with  cream. 

Fats  and  Oils. — Fats  and  oils  are  indicated  in  tubercular  disease, 
and  especially  in  pulmonary  phthisis,  in  as  large  amounts  as  the  pa- 
tient may  be  able  to  digest.  Crisp  fat  bacon,  butter,  cream,  whole 
milk,  egg  yolk,  cod-liver  oil,  and  olive  oil  all  furnish  desirable  forms 
of  fat  when  the  intestine  absorbs  them. 

While  fat  is  being  taken  it  is  well  to  occasionally  observe  the  stools 
to  see  that  none  passes  away  undigested,  and  if  any  one  fat  disa- 
grees and  causes  dyspepsia  its  use  must  be  restricted,  or  temporarily 
withheld  while  another  is  tried.  As  a  rule,  cream,  butter,  and  cod- 
liver  oil  will  prove  the  best.  Fats,  well  digested,  seem  in  some  in- 
stances to  have  an  almost  curative  power,  so  greatly  do  nutrition  and 
body  weight  improve  during  their  use. 

Cod-liver  Oil. — The  use  of  cod-liver  oil  in  phthisis  should  be 
determined  by  the  condition  of  the  digestive  organs  and  the  general 
nutrition  of  the  patient.  Wherever  the  digestion  is  fairly  good,  in 
the  absence  of  gastric  catarrh,  the  oil  is  of  great  nutritive  value,  and 
it  is  usually  well  borne  when  properly  administered.  If  there  is  much 
gastric  catarrh  or  if  the  stomach  is  irritable  and  nausea  is  easily  ex- 
cited, persistence  in  the  use  of  the  oil  will  only  make  matters  worse. 
It  should  be  at  least  temporarily  discontinued,  though  in  the  chronic 
forms  of  tuberculosis  unaccompanied  by  fever,  in  which  debility  and 
emaciation  predominate,  cod-liver  oil  is  often  well  tolerated. 

Cod-liver  oil  is  on  the  whole  more  satisfactory  for  children  than 
adults,  particularly  in  cases  of  tuberculosis  in  which  the  bones  or 
glands  are  enlarged. 

The  presence  of  diarrhoea  is  to  be  regarded  as  a  contraindication 
for  the  administration  of  cod-liver  oil,  but  unless  it  is  given  in  large 
quantities  it  has  very  little  if  any  laxative  effect  upon  adults,  and  it 
may  usually  be  continued  in  doses  of  a  drachm  two  or  three  times  a 
day,  with  no  ill  effect,  and,  in  fact,  by  improving  the  nutrition  it  may 
sometimes  benefit  diarrhoea.  Ringer  suggests  that  for  this  class  of 
patients  a  teaspoonful  or  more  of  the  oil  given  at  night  before  sleep 
may  be  better  borne  than  at  any  other  time  in  the  day.  The  state- 
ment is  usually  made  that  persons  with  phlegmatic  temperaments,  with 
dark,  sallow  complexions,  derive  more  nutrition  from  cod-liver  oil 
than  do  others,  but  it  is  doubtful  whether  it  can  be  applied  any  more 
distinctly  to  cod-liver  oil  than  to  other  classes  of  food. 


.^.  DIET   IN    DISEASE. 

Commonly  it  is  best  to  give  the  oil  pure  and  uncombined  if  it 
can  be  tolerated.  It  may  be  given  in  capsules,  although  they  are 
not  always  dissolved  at  the  proper  time  in  the  stomach.  Patients 
who  require  alcohol  may  take  the  oil  in  whisky.  For  the  many  dif- 
ferent methods  of  administering  it  and  of  disguising  its  taste  the 
reader  is  referred  to  the  section  on  Cod-liver  Oil  (page  182).  The 
newly  isolated  active  principle  of  the  oil,  called  gaduin,  has  been 
employed  with  some  degree  of  success  (page  180). 

Alcohol. — Alcohol  is  not  believed  to  possess  any  specific  action 
in  phthisis,  and  in  many  cases  it  is  positively  harmful.  As  a  rule,  if 
patients  have  a  fair  appetite  and  are  improving  in  strength  its  use  is 
contraindicated.  When  alcohol  is  required  as  a  food  and  tonic  rather 
than  as  a  stimulant,  the  best  form  in  which  to  give  it  is  that  of  malt 
liquor  or  light  wine.  One  or  two  pints  daily  may  be  prescribed  of 
beer,  stout,  or  porter,  or  half  a  pint  of  claret  or  sound  Burgundy  is 
useful  if  anaemia  is  marked.  The  light  Hungarian,  Italian,  or  Greek 
wines  may  be  used  by  those  whose  purse  places  them  within  reach. 
One  of  the  Tokay  wines,  with  cocoa,  may  be  prescribed.  Sweet 
wines,  sherry,  port,  Madeira,  and  champagne  are  not  as  useful. 
They  are  more  apt  to  disagree,  and  cause  dyspepsia  and  headache. 

The  promiscuous  habit  of  daily  drinking  rum,  whisky,  or  other 
strong  liquors  in  tuberculosis  is  to  be  condemned,  although  nearly 
all  cases  at  some  time  in  their  course  demand  alcoholic  stimulation. 

No  class  of  patients  exhibits  more  painfully  and  rapidly  the  inroads 
of  the  disease  than  those  who  for  a  long  time  have  been  preserving 
their  own  tissues,  like  pathological  specimens,  in  daily  draughts  of 
strong  alcohol.  The  cirrhotic  changes  which  occur  in  various  or- 
gans are  the  best  possible  preparation  for  the  advancement  of  tuber- 
cular processes.  If  the  exhibition  of  alcohol  increases  the  tempera- 
ture and  the  pulse  rate,  and  is  followed  immediately  by  greater 
weakness,  it  is  doing  harm  (Loomis).  Advanced  cases  of  tubercu- 
losis show  great  toleration  for  alcohol,  but  it  does  not  follow  that 
it  is  proportionately  benefiting  them.  When  in  the  course  of  an 
ordinary  case  the  hectic  fever  becomes  high  and  exhausting,  the 
pulse  feeble  and  rapid,  and  the  digestion  fails,  it  may  be  best  to 
lessen  the  quantity  of  food  and  give  more  stimulation.  Usually 
three  or  four,  but  seldom  more  than  eight,  ounces  of  whisky,  brandy, 
or  rum  may  be  required  daily  for  this  purpose.  Special  pains  should 
be  taken  to  use  only  such  liquors  as  are  strictly  pure  and  of  the  best 
quality. 

Diet  in  Mild  Cases. 

The  following  liberal  menu  will  furnish  abundant  variety  from 
which  to  select  the  dietary  for  tubercular  patients  in  whom  the  prog- 
gress  of  active  lesions  is  in  abeyance  or  completely  arrested,  and  in 
whom  there  is  little  or  no  gastric  catarrh : 


TUBERCULOSIS. 


435 


FOODS  ALLOWED    IN   NON-ACTIVE   CASES   WITHOUT   GASTRIC 

CATARRH. 

Soups  and  broths :  Mutton,  oyster,  clam,  barley,  vermicelli,  bou- 
illon, chicken  with  rice. 

Purees  of  peas,  beans,  tomatoes,  celery.  It  is  often  well  to  add 
to  them  meat  extracts,  peptonoids,  beef  meal,  etc. 

Milk  or  cream  in  any  form,  including  buttermilk  and  koumiss, 
clotted  or  Devonshire  cream,  whipped  cream,  etc. 

Shellfish :  Oysters  or  clams,  either  raw,  roasted,  or  broiled  (the 
livers  or  "soft  parts"  only). 

Fish  of  any  kind  if  fresh,  either  boiled  or  broiled  (never  fried), 
sardines  (if  they  "  agree  "  )  for  the  sake  of  the  oil. 

Eggs,  preferably  raw  or  very  lightly  cooked,  or  in  eggnog  or  cus- 
tard, also  poached,  scrambled,  or  in  plain  omelet  (never  hard-boiled). 

^[eats :  Beefsteak,  rare  roast  beef,  scraped-beef  sandwiches  or 
meat  balls,  lamb  or  mutton,  roasted  or  boiled  ;  chops  ;  chicken,  capon, 
turkey,  either  roasted,  boiled,  or  broiled. 

Game :  Partridge,  squab,  woodcock,  snipe,  prairie  chicken,  quail, 
roasted  or  broiled. 

Meats,  especially  beef  and  mutton,  should  predominate.  Gelatin 
may  be  used,  but  it  is  not  very  nutritious.  It  should  be  combined 
with  meal  or  meat  preparations. 

Entrees  :    Sweetbreads. 

Fats  and  oils  (as  much  as  can  be  digested) :  Good  fresh  butter, 
olive  oil  on  lettuce  or  raw  tomatoes,  cod-liver  oil,  the  fat  of  beef  or 
mutton  (if  it  "agrees"),  cream  (on  everything  with  which  it  can  be 
appropriately  eaten),  a  little  fat  bacon.  Pancreatin  or  pancreatic 
emulsions  will  aid  the  digestibility  of  fats. 

Vegetables :  Baked  potatoes,  tomatoes  stewed  or  raw,  very  young 
green  peas,  string  beans,  spinach,  celery  (stewed),  onions,  boiled 
asparagus,  lettuce,  cauliflower. 

All  vegetables  to  be  eaten  in  moderation. 

Cereals:  Whole-meal  bread,  wheaten  or  rye  only  if  stale  or 
toasted.  Zwieback,  rusk,  milk  toast,  cream  toast,  crackers,  malted 
bread  and  biscuit,  rice  in  any  form,  mush,  hominy,  farina,  cracked 
wheat,  wheaten  grits,  oatmeal,  macaroni,  spaghetti. 

Some  authors  recommend  lentil  flour,  on  the  ground  that  it  con- 
tains both  iron  and  phosphorus.  Oatmeal  contains  considerable  fatty 
matter,  and  maize  has  still  more.  All  cereals  are  to  be  eaten  spar- 
ingly. 

Fruits :  Apples,  baked  or  stewed,  oranges,  shaddock,  grapes,  pears, 
peaches,  plums,  strawberries,  blackberries,  olives. 

Desserts:  Wine  jelly,  custard,  blancmange,  rice  pudding,  bread 
pudding,  junket  and  cream,  Bavarian  cream. 


.-5  I>IET   IN    DISEASE. 

Avoid  fried  foods,  rich  sauces,  pastry,  cakes,  hot  breads,  ragotits, 
beans,  carrots,  turnips,  cabbage,  confectionery,  puddings,  dried  foods, 
salt  fish  or  meats  (except  as  specified  above). 

Beverages  Allowed. — Water,  tea,  coffee,  cocoa,  milk,  koumiss,  mat- 
zoon,  buttermilk,  milk  punch,  lemonade  or  orangeade,  Vichy  or  other 
aerated  water,  non-fermented  grape  juice,  malt  extracts. 

Alcohol :  Beer,  ale,  porter,  wines,  liquors,  are  permissible  only  if 
needful  for  special  symptoms — that  is,  if  desirable  for  food  or  to  aid 
digestion  and  promote  exercise. 

H.  P.  Loomis  gives  the  following  useful  sample  diet,  with  the  ap- 
propriate intervals  for  taking  food.  A  glass  or  two  of  milk  may  be 
added  at  night  with  advantage : 

"  On  Awakening. — Eight  ounces  of  equal  parts  of  hot  milk  and 
Seltzer,  taken  slowly  through  half  an  hour. 

^'■Breakfast. — Oatmeal  or  cracked  wheat,  with  a  little  sugar  and 
an  abundance  of  cream,  rare  steak,  or  loin  chops  with  fat ;  soft- 
boiled  or  poached  ^gg,  cream  toast,  half  pint  of  milk,  small  cup  of 
coffee. 

'''■Lunch,  lo  A.  M. — Half  pint  of  milk  or  small  teacup  of  squeezed 
beef  juice,  with  stale  bread.     12,  noon  :    Rest  or  sleep. 

^^  Midday  Meal,  12.30. — Fish,  broiled  or  stewed  chicken,  scraped- 
meat  ball,  stale  bread,  and  plenty  of  butter,  baked  apples  and  cream, 
two  glasses  of  milk. 

^^  Lunch,  4  p.  M. — Bottle  koumiss,  raw  scraped-beef  sandwich,  or 
goblet  of  milk.     5.30  p.  m.  :    Rest  or  sleep. 

"Dinner,  6  p.  m. — Substantial  meat  or  fish  soup,  rare  roast  beef  or 
mutton,  game,  slice  stale  bread,  spinach,  cauliflower,  fresh  vegetables 
in  season  (sparingly)." 

Diet  in  Advanced  Cases. 

It  not  rarely  happens  that  patients  who  have  suffered  much  from 
indigestion  in  the  earlier  stages  of  phthisis  finally  reach  a  condition 
in  which,  although  greatly  emaciated  and  prostrated,  they  seem  able 
to  eat  and  digest  a  much  larger  variety  and  quantity  of  food  than 
before.  As  these  cases  are  utterly  hopeless,  it  is  often  best  to  let 
such  patients  select  their  own  diet,  providing  only  that  it  is  nutri- 
tious and  of  a  quality  which  does  not  excite  cough  or  diarrhoea. 

If  the  bowels  are  not  too  loose,  fresh  fruit,  especially  oranges, 
may  be  allowed,  and  proves  very  refreshing. 

In  very  advanced  cases,  and  in  all  cases  during  acute  exacerba- 
tions of  severity,  with  marked  prostration,  the  patient  must  have 
food  every  two  or  three  hours,  and  the  intervals  of  feeding  should 
never  be  longer  than  the  latter.  A  diet  consisting  very  largely  of 
milk  or  milk  and  cream  is  best,  but  broths  and  pancreatinised  meat 
preparations,  albumoses,  and  egg  albumen  may  be  added. 


TUBERCULOSIS. 


437 


Milk  Diet. — Milk  is  a  food  which  is  especially  adapted  for  con- 
sumptives, many  of  whom  do  best  when  living  upon  it  almost  ex- 
clusively, while  others  should  drink  it  freely  in  connection  with 
other  nourishment.  It  is  fattening,  is  assimilated  without  over- 
taxing the  digestive  organs,  and  taken  hot,  either  alone  or  with  an 
equal  part  of  Vichy,  it  is  soothing  to  the  throat  and  ameliorates  the 
cough. 

Advanced  cases  of  tuberculosis  living  upon  full  milk  diet  should 
take  between  two  and  a  half  and  four  quarts  a  day,  but  not  over 
eight  ounces  at  once.  It  should  be  sipped,  or  really  eaten,  and  not 
drunk,  for  it  then  will  coagulate  by  slow  degrees  in  the  stomach  and 
not  form  large  indigestible  curds.  This  should  be  insisted  upon  and 
ten  minutes  should  be  occupied  in  drinking  half  a  pint.  If  the  milk 
(disagrees  at  first  it  may  be  modified  in  any  one  of  the  ways  sug- 
gested on  page  64,  but  it  is  best  not  to  give  it  in  connection  with 
beef  juice. 

In  this  country  cow's  milk  is  preferred,  but  elsewhere  the  milk  of 
other  animals  serves  equally  well.  Goat's  milk,  drunk  largely  in 
Switzerland,  contains  more  salts  of  lime  and  is  good  for  cases  of 
tubercular  diarrhoea,  and  sometimes  ass's  or  mare's  milk  proves 
more  digestible.     The  latter  varieties  are  principally  used  in  Russia. 

Lebert's  Milk  Cure  (from  Bauer). — "  Lebert  directs  the  pa- 
tient to  drink  slowly  three  hundred  to  five  hundred  grammes  of  milk 
every  morning  and  evening,  between  five  and  six  o'clock,  fasting. 
He  prefers  it  freshly  drawn  from  the  cow,  and  if,  in  consequence  of 
having  stood  for  some  time,  a  separation  of  the  cream  has  already 
begun,  recommends  it  to  be  skimmed  off. 

"  During  the  continuance  of  the  milk  treatment  the  patient  is  al- 
lowed a  substantial  dinner,  at  least  of  soup,  roast  meat,  young 
vegetables,  stewed  fruit,  etc.,  and  a  little  beer  or  wine.  At  the  dis- 
cretion of  the  physician  a  proper  breakfast  may  be  taken  an  hour 
after  the  morning's  milk  of  a  cup  of  tea  with  plenty  of  milk  and  bis- 
cuits and,  perhaps,  one  or  two  light-boiled  eggs,  and  again  in  the 
evening  a  good  soup,  as  well  as,  when  possible  (i.  e.,  in  the  case  of 
non-febrile  patients),  some  more  roast  meat.  If  milk  is  well  borne, 
the  regular  breakfast  and  supper  may  be  supplemented  by  further 
doses  of  one  hundred  to  two  hundred  grammes  of  milk." 

Whey  or  koumiss  may  be  drunk  instead  of  milk.  For  those  who 
can  digest  it,  cream  is  an  excellent  food.  With  some  patients  cream 
diluted  with  an  equal  bulk  of  hot  water  agrees  even  better  than 
milk.  The  taste,  if  complained  of,  may  be  modified  by  a  very  little 
tea  or  coffee,  or  salt  or  sugar.  Yeo  sometimes  adds  a  teaspoonful 
of  rum  or  brandy  or  aromatic  spirits  of  ammonia.  Some  patients 
can  take  a  quart  of  cream  besides  a  quart  and  a  half  of  mWk  per  diem 
with  profit. 


438 


DIET   IN   DISEASE. 


SURALIMENTATION. 

Suralimentation,  called  also  "superalimentation,"  or  "forced 
feeding,"  is  based  upon  the  theory  that  the  best  method  to  combat 
the  symptoms  of  phthisis  is  by  "  stuffing  "  the  patient  with  all  the 
food  which  he  can  possibly  digest.  More  food  is  needed  than  in 
health  to  counterbalance  rapid  tissue  waste.  The  appetite  is  not 
always  a  reliable  indication  of  the  strength  of  the  digestive  organs, 
and,  acting  upon  this  fact,  Debove  introduced  the  plan  of  feeding 
by  means  of  the  oesophageal  tube.  It  is  only  necessary  to  use  this 
method  when  a  patient  loses  all  appetite,  or  acquires  a  positive  dis- 
gust for  food,  and  rapidly  emaciates  in  consequence.  The  tube  is 
employed  in  the  manner  described  for  feeding  cases  of  insanity,  and 
any  form  of  desirable  fluid  food  is  introduced  through  it.  It  is 
sometimes  only  necessary  to  pass  the  tube  to  the  level  of  the  oesoph- 
agus, and  the  first  few  times  that  it  is  used  it  may  be  well  to  brush 
the  pharynx  with  a  two-per-cent  solution  of  cocaine.  The  meals 
may  be  given  three  or  four  times  a  day,  or  a  patient  whose  appetite 
is  not  wholly  lost,  but  is  inadequate,  may  prefer  to  eat  part  of  his 
food  himself  and  have  other  meals  furnished  through  the  tube. 

The  following  are  the  foods  most  suitable  for  tube  feeding: 
I.  Milk  and  its  preparations;  cream.  2.  Raw  eggs,  eggnog.  3.  Meat 
extracts,  beef  meal  or  powder.  4.  Leguminous  purees  and  cereals, 
thoroughly  cooked  and  made  fluid  by  predigestion  with  malt  extract. 
A  quart  may  be  given  at  a  time.  If  gastric  catarrh  is  present  the 
gavage  should  be  preceded  by  lavage. 

Debove,  speaking  of  his  method,  says:  "A  patient  who  has  no 
appetite,  or  who  has  a  decided  disgust  for  all  food,  will  digest  per- 
fectly a  large  meal  introduced  by  the  tube,  and  even  at  the  end  of  a 
certain  time  will  recover  appetite." 

His  method  is  first  to  wash  out  the  stomach  with  cold  water,  and 
then  pour  in  through  the  tube  a  litre  of  milk,  one  hundred  grammes 
of  fine  meat  powder,  and  an  egg. 

He  adds  that  with  suralimentation  night  sweats,  cough,  and  ex- 
pectoration are  all  reduced  or  disappear  completely,  while  there  is 
considerable  gain  in  weight  and  strength  and  improvement  in  the 
physical  signs  in  the  chest. 

Suralimentation  may  also  be  conducted  without  the  stomach  tube 
in  patients  who  are  able  and  willing  to  eat.  They  maybe  given  five 
or  six  meals  a  day.  This  appHes  to  patients  who  are  not  having 
severe  hectic  fever,  and  in  whom  gastric  catarrh  is  not  a  prominent 
symptom.  Should  vomiting  occur  during  the  treatment,  it  will  be 
necessary  to  suspend  it  until  the  stomach  is  again  in  order.  As  a 
rule,  in  such  instances  it  is  better  to  discontinue  medicines  than 
food,  if  both   are  being  taken.     The  presence  of  moderate  fever— 


TUBERCULOSIS. 


439 


one  or  two  degrees — is  not  in  itself  alone  a  contraindication  for 
forced  feeding,  or  for  keeping  the  patient  confined  to  bed.  The 
gain  of  appetite  which  often  accompanies  removal  to  a  favourable 
climate  may  be  utilised  to  promote  forced  feeding. 

The  following  diet  recommended  by  Solis-Cohen  serves  as  a  good 
illustration  of  the  proper  regimen  in  the  cases  under  discussion : 

"Diet  for  Forced  Feeding. 

"The  patient  is  to  take  a  pint  of  hot  water  in  the  early  morning 
to  stimulate  the  stomach  and  cleanse  it  of  mucus  accumulated  over- 
night. 

"  A  half  hour  after  the  morning  bath,  milk  punch  and  beef  meal 
or  peptonoids. 

"  Breakfast,  a  half  hour  later,  consisting  of  rare  steak  or  chop, 
eggs,  sliced  tomatoes,  bread  with  plenty  of  butter,  or  cracked  wheat 
and  cream.  In  two  hours,  koumiss  or  soup,  milk,  bread  and  butter, 
celery  salad,  broth,  and  peptonoids. 

"Dinner^  i  p.  M. — Bouillon,  rare  beef,  greens,  Burgundy,  beer, 
fruits. 

"3^r4P.  M. — Koumiss,  cream,  or  milk  punch,  peptonoids,  malt 
extract.  , 

"  7  p.  M. — Supper,  like  breakfast. 

"  9  or  ID  p.  M. — Cream  and  cocoa  or  coca  wine,  milk,  and  pep- 
tonoids." 

The  patient  should  keep  milk,  or  peptonoids,  or  some  nutritious 
beverage  by  the  bedside  to  be  drunk  if  he  awakens  in  the  middle  of 
the  night. 

Another  diet  well  suited  to  some  patients  is  thus  outlined  by 
Weber  in  his  Croonian  Lectures  for  1885  : 

"  7  A.  M. — While  still  in  bed,  a  cup  of  milk  with  a  dessertspoonful 
of  Cognac  or  lime  water,  or  a  cup  of  tea  or  cocoa,  with  bread  and 
butter. 

"  8.30  to  9  A.  M. — After  dressing,  milk  and  tea  or  coffee,  bread  and 
butter,  fish,  ham,  or  bacon. 

"n  A.M. — Milk,  koumiss,  or  broth,  or  a  sandwich  and  glass  of 
wine. 

"i  to  1.30  P.M. — A  substantial  meal  of  meat,  poultry,  fish  or 
game,  fresh  vegetables,  a  light  pudding,  fruit,  and  a  glass  of  wine. 

"4  P.M. — Milk  or  koumiss,  tea  or  coffee,  with  bread  and  but- 
ter or  biscuit. 

<'  7  P.  M. — Another  meal  like  that  at  i  p.  m. 

"9.30 /^  10  P.  M. — A  cup  of  milk,  bread  and  milk,  or  milk  or 
cream  and  farinaceous  food,  such  as  Hart's,  Liebig's,  Nestl^'s,  or 
Mellin's.     A  glass  of  brandy  if  there  are  night  sweats." 

The  question  may  properly  be  asked  whether  it  is  not  possible 


.  .Q  DIET    IN    DISEASE. 

to  overfeed  patients  in  this  manner  ?  This  will  happen  when  the 
increase  in  body  weight  exceeds  the  breathing  capacity  of  the  lungs — 
in  other  words,  when  the  facilities  for  oxygen  supply  are  dispropor. 
tionate  to  the  bulk  of  tissue  to  be  supplied.  The  symptoms  will  be 
a  coated  tongue  with  dyspepsia  and  biliousness,  increased  pulse 
frequence,  and  possibly  increased  dyspnoea  on  exertion,  all  occurring 
without  aggravation  of  the  local  physical  signs.  The  food  must 
then  be  reduced  in  amount.  Both  fluids  and  solids  are  to  be  re- 
stricted, and  fish  may  replace  meat  temporarily. 

Aids  to  Dietetic  Treatment. 

It  is  not  within  the  scope  of  this  work  to  discuss  the  details  of 
hygiene,  but  they  should  be  at  least  mentioned  as  important  ad- 
juncts to  dietetic  treatment.  In  those  cases  especially  in  which 
forced  feeding  is  recommended  it  is  desirable  to  promote  oxidation 
in  every  way.  Patients  should  live  in  the  open  air  all  they  can,  and, 
if  possible,  should  go  to  a  climate  which  enables  them  to  be  outdoors 
all  day  long.  Habits  of  moderate  exercise,  instruction  in  proper 
methods  of  breathing,  cold  bathing,  massage,  and  reasonable  mental 
diversion  and  good  cheer  are  all  useful  factors  in  improving  the 
digestion  and  assimilation  of  food.  Worry  and  nervous  strain  of 
every  kind  should  be  avoided. 

Of  the  long  list  of  medicinal  remedies  which  have  from  time  to 
time  won  favour  or  notoriety  for  the  treatment  of  tuberculosis,  those 
which  have  best  withstood  the  test  of  practical  experience  are  the 
ones  which,  like  creosote,  act  mainly  by  maintaining  asepsis  and 
preventing  malfermentation  in  the  alimentary  canal.  It  is  imma- 
terial whether  cod-liver  oil  be  considered  as  a  medicine  or  as  a  food. 
It  has  already  been  discussed  as  a  food.  In  a  negative  way  it  should 
be  stated  that  one  of  the  best  aids  to  digestion  consists  in  prevent- 
ing the  patient  from  disordering  the  stomach  and  the  appetite  with 
all  manner  of  cough  mixtures  and  ill-advised  tonics. 

Such  medicines  as  may  from  time  to  time  be  required  for  emer- 
gencies will  be  much  better  absorbed  if  the  stomach  has  not  been 
long  kept  in  a  state  of  dyspeptic  irritability. 

Diet  "Cures"  for  Phthisis. 

Many  special  forms  of  dietetic  treatment  have  been  devised  and 
extensively  practised  for  the  cure  of  pulmonary  tuberculosis.  The 
details  of  these  "  cures  "  are  elsewhere  described.  The  principal 
ones  are  the  "  Milk  Cure  "  (page  44),  the  "Whey  Cure,"  the  "Kou- 
miss Cure"  (page  71),  practised  chiefly  in  the  steppes  of  south- 
eastern Russia,  and  the  "  Grape  Cure  "  conducted  at  Meran,  Mon- 
treux,  and  elsewhere  in  the  months  of  September  and  October. 
Aside  from  climatic  influences   and  the   effects   of   good   hygienic 


THE   RESPIRATORY   SYSTEM. 


441 


surroundings,  their  benefits  are  attributable  only  to  the  fact  that 
the  patient  is  encouraged  to  take  a  large  quantity  of  easily  di- 
gestible food  and  live  constantly  in  the  open  air.  Patients  with 
chronic  phthisis  are  notoriously  sanguine  as  to  the  possibilities  of 
their  ultimate  recovery,  and  it  is  also  true  that  their  mental  state 
reacts  to  a  greater  degree  upon  their  physical  condition  than  in 
almost  any  other  disease. 

All  manner  of  absurd  foods,  such  as  fish  roes  in  Germany  and 
snails  in  the  south  of  France,  have  achieved  fame  with  credulous 
persons  as  possessing  specific  virtues  in  the  cure  of  phthisis.  It 
should  be  as  much  the  duty  of  the  physician  to  protect  them  from 
the  chagrin,  disappointments,  and  expense  of  following  dietetic  illu- 
sions as  to  encourage  them  in  every  reasonable  effort  for  improve- 
ment. Beyond  the  requirements  of  a  good,  nourishing,  easily  diges- 
tible diet,  there  is  no  specific  food  "cure  "  for  tuberculosis,  as  there 
is  no  medicinal  cure. 


DIET   IN   DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

Laryngismus  Stridulus, 

In  children  who  are  subject  to  spasmodic  croup  the  .ittacks  are 
often  precipitated  by  dyspepsia  caused  by  overfeeding  and  nurs- 
ing, by  improper  food,  or  by  constipation.  The  diet  must  therefore 
be  regulated  according  to  the  rules  laid  down  under  the  heading 
Infant  Feeding.  The  habit  of  night  feeding  especially  should  be 
given  up  after  the  first  month  of  life.  This  can  usually  be  done 
after  two  or  three  trials.  If  the  infant  awakens  crying  at  night  it 
must  be  offered  a  little  cool  water,  and  it  may  presently  drop 
asleep.  Up  to  the  fourth  month  six  meals  a  day,  three  hours  apart, 
are  all  that  are  allowed,  and  from  that  time  on  until  the  second 
year  five  meals  must  suffice. 

Between  the  attacks  the  milk  should  be  lessened  in  amount,  and 
so  modified  as  to  insure  more  perfect  digestion.  Children  over  six 
months  of  age  should  be  given  from  one  to  three  tablespoonfuls  of 
pressed  beef  juice  in  a  day. 

Older  children  had  better  be  kept  upon  a  fluid  diet  of  meat 
broths,  milk,  and  egg  albumen,  solid  food  being  withheld  until  the 
seizures  abate.     Cod-liver  oil  should  be  given  in  most  cases. 

Tubercular  Laryngitis. 

In  tubercular  laryngitis  intense  pain  is  excited  by  the  act  of 
deglutition.  Nutritious  but  non-irritating  food  is  therefore  required. 
Thick  soups  and  gruels,  purees,  cream,  beaten  raw  eggs,  scraped 
rare  beef,  raw  oysters,  junket,  can  all  be  swallowed  more  readily 


.,^  ^  DIET   IN   DISEASE. 

442 

than  very  fluid  or  solid  food.     Strong  condiments,  vinegar,  and  salt 
must  be  avoided,  for  they  increase  the  pain. 

The  difficulty  experienced  in  deglutition  is  considerably  relieved 
by  the  method  proposed  by  Wolfenden,  which  is  to  have  the  patiei\t 
lie  prone  on  a  lounge,  and  with  his  face  protruding  over  the  lower 
edge  he  is  to  suck  through  a  glass  tube  semifluid  food  from  a  tumbler 
on  the  floor.  Sajous  advises  the  patient  to  lean  over  forward  when 
eating,  which,  he  says,  "  causes  the  food  to  pass  down  along  the 
pyriform  sinuses,  thus  avoiding  the  upper  portion  of  the  larynx, 
contact  with  which  causes  the  severe  pain  experienced  by  advanced 
cases  during  the  act  of  deglutition." 

HEMORRHAGE   OF  THE   LUNGS. 

Haemorrhage  of  the  lungs,  or  rather  from  the  bronchial  mucous 
membrane,  when  occurring  suddenly  and  in  considerable  amount, 
greatly  reduces  the  strength,  and  naturally  alarms  the  patient  and 
excites  the  nervous  system.  Absolute  quiet  must  be  immediately 
secured  by  rest  in  bed  without  a  pillow,  so  that  the  body  may  lie 
flat,  and  the  head  and  arms  should  on  no  account  be  raised.  The 
room  should  be  kept  quiet  and  the  patient  must  not  be  allowed  to 
speak  or  to  feed  himself.  A  reliable  and  quiet  nurse  should  be 
secured  for  him,  and  he  should  be  fed  upon  a  nutritious  diet,  which 
requires  no  effort  in  eating.  Small  quantities  only  of  fluid  should  be 
given  at  one  time  through  a  glass  tube  or  by  a  teaspoon,  so  that 
the  head  need  not  be  raised.  If  nausea  occurs,  every  effort  must 
be  made  to  control  it,  for  the  violent  muscular  action  and  the  tem- 
porary circulatory  and  respiratory  disturbances  occasioned  by  the 
act  of  vomiting  might  excite  further  haemorrhage.  It  is  desirable  to 
reduce  the  blood  pressure  in  the  lungs  as  much  as  possible  in  order 
to  allow  coagulation  of  the  blood  to  occur  over  the  oozing  sur- 
face of  the  bronchial  mucous  membrane,  and  therefore  large  quan- 
tities of  fluid  should  not  be  given  at  first.  The  patient  is  usually 
thirsty  from  the  loss  of  blood  and  temporary  drying  of  secretions. 
The  thirst  may  be  relieved  by  crushed  ice  and  small  quantities  of 
cold  acidulated  drinks,  such  as  very  dilute  phosphoric  acid  or 
sour  lemonade,  and  if  the  stomach  is  in  normal  condition,  plain 
milk  may  be  given  or  else  pancreatinised  milk  and  strong  beef 
broth  in  quantities  not  exceeding  two  or  three  ounces  in  as  many 
hours. 

It  is  customary  to  administer  all  fluids  cold,  but  the  advantage 
of  this  is  overrated.  Warm  fluids  have  a  somewhat  more  stimulat- 
ing effect  upon  the  heart,  and  are  more  rapidly  absorbed,  but  the 
idea  sometimes  advanced  that  the  cold  of  iced  fluids  taken  into  the 
stomach  is  ever  sufficient  to  constrict  the  bleeding  bronchial  ves- 
sels, even  by  supposed  reflex  action,  does  not  appear  rational.     For 


THE   RESPIRATORY   SYSTEM. 


443 


a  full  discussion  of  this  question  the  reader  is  referred  to  experi- 
ments reported  upon  page  311. 

If  coincident  gastric  disorder  is  present  with  bronchial  haemor- 
rhage, to  forestall  vomiting  it  may  be  better  to  resort  to  nutritious 
enemata. 

In  cases  where  exceptionally  large  quantities  of  blood  have  been 
lost,  the  blood  pressure  may  be  greatly  reduced  and  the  danger  of 
death  from  heart  failure  may  appear  imminent.  It  then  becomes 
necessary  to  give  a  larger  quantity  of  fluid,  and  the  rules  in  regard 
to  the  dietetic  treatment  of  severe  and  sudden  hemorrhage  taking 
place  anywhere  from  the  body  must  be  observed.  Salt  and  water, 
a  teaspoonful  to  the  pint,  may  be  injected  into  the  rectum,  or  even 
beneath  the  skin.  Most  cases,  however,  are  more  mild,  and  after  a 
few  hours  of  rest  and  quiet,  furthered,  perhaps,  by  the  hypodermic 
injection  of  morphine,  the  patient  will  be  able  to  retain  a  little  sim- 
ple semisolid  food,  such  as  milk  toast,  a  beaten  egg,  junket,  etc. 

If  there  is  no  return  of  the  haemorrhage  in  a  day  or  two,  the 
diet  should  be  increased  and  anaemia  consequent  upon  the  bleeding 
must  be  treated  by  an  abundant  meat  diet.  As  a  rule,  alcoholic 
stimulants  should  be  avoided,  on  account  of  the  relation  of  blood 
pressure  to  the  bleeding,  or  they  should  be  given  in  moderation, 
unless  the  danger  of  heart  failure  is  imminent. 

Acute  Capillary  Bronchitis. 

In  acute  capillary  bronchitis  in  infants  and  children  a  wholly 
fluid  diet  of  the  simplest  but  most  nutritious  kind  must  be  enforced. 
In  young  infants  milk  alone,  in  older  children  milk,  meat  juice,  meat 
broths,  and  beaten  eggs  or  egg  albumen,  should  be  fed  at  least  every 
two  hours  in  such  quantities  as  the  stomach  will  bear.  It  may  be 
best  to  pancreatinise  all  food.  Very  feeble  children  will  require 
food  oftener,  and  sometimes  a  teaspoonful  only  should  be  ordered 
once  every  fifteen  or  twenty  minutes.  If  the  child  refuses  food  or 
vomits  constantly,  nutrient  enemata  (page  375)  must  be  prescribed 
once  in  three  or  four  hours.  Brandy  is  the  best  stimulant  for  these 
cases;  it  is  well  borne,  and  should  be  given  early  and  often. 

Chronic  Bronchitis. 

The  diet  for  chronic  bronchitis  is  substantially  the  same  as  that 
recommended  for  the  earlier  stages  of  pulmonary  phthisis,  to  which 
the  reader  is  referred  (page  434). 

The  cough  is  often  momentarily  relieved  by  drinking  hot  lemon- 
ade, hot  milk  and  Seltzer  or  Vichy,  glycerin  and  whisky,  and  some- 
times by  sucking  a  raw  egg  through  the  perforated  shell. 


DIET   IN   DISEASE. 
444 

Asthma. 

Spasmodic  bronchial  asthma  is  believed  to  be  occasioned  by 
temporary  spasm  of  the  bronchial  muscles  which  narrows  the  lumen 
of  the  tubules  and  obstructs  the  free  entrance  and  exit  of  air.  It  is 
also  attributed  to  hyperaemia  and  swelling  of  the  bronchial  mucous 
membrane,  and  possibly,  in  some  cases,  to  a  reflex  spasm  of  the  dia- 
phragm and  other  muscles  of  inspiration.  Asthmatic  patients  soon 
find  from  experience  that  errors  in  diet  are  liable  to  precipitate  an  at- 
tack, and  overloading  the  stomach  or  eating  particular  kinds  of  food, 
which  are  unwholesome  or  against  which  the  individual  possesses 
some  idiosyncrasy,  may  excite  dyspnoea.  Aitkin  showed  a  true  ap- 
preciation of  the  importance  of  diet  in  this  disease  when  he  wrote: 
"  More  is  to  be  done  for  asthmatic  patients  on  the  side  of  the  stom- 
ach than  in  any  other  direction,"  and  "  the  asthmatic  can  never  with 
impunity  eat  and  drink  as  other  people." 

Accumulation  of  large  quantities  of  undigested  and  fermenting 
food  results  in  the  production  of  gas  in  both  the  stomach  and  intes- 
tines, which  become  distended  and  by  pressure  interfere  with  the 
movements  of  the  diaphragm  and  abdominal  muscles  in  free  respira- 
tion. The  chemical  irritation  of  undigested  food  may  be  a  cause  of  re- 
flex spasm  of  various  muscles,  and  may  possibly  affect  those  of  respira- 
tion. It  is  therefore  necessary  for  asthmatics  to  exercise  care  in  the 
selection  of  their  food  and  to  keep  the  digestive  organs  in  as  nor- 
mal a  condition  as  possible.  All  food  which  is  constipating  or 
which  is  liable  through  fermentation  to  evolve  large  quantities  of 
gas  should  be  shunned.  In  general,  fats  and  sweets  should  be 
given  up,  and  starchy  food,  if  eaten  at  all,  must  be  very  thoroughly 
cooked  and  slowly  masticated,  in  order  that  the  salivary  digestion  of 
it  may  be  as  complete  as  possible.  Pork,  veal,  and  cheese  must 
never  be  eaten,  and  elaborate  cooking  and  desserts  are  forbidden. 
No  water  should  be  allowed  with  meals  or  until  at  least  three  hours 
thereafter.  A  cup  of  very  hot  water  may  be  drunk  an  hour  before 
each  meal  and  again  at  night. 

In  most  persons  the  asthmatic  attacks  are  worse  at  night,  and  in 
many  they  only  occur  at  that  time.  It  is  consequently  better  for 
them  to  take  the  principal  meal  of  the  day  at  noon  and  to  eat  a 
light  supper,  so  that  gastric  digestion  may  be  finished  before  going 
to  bed. 

The  following  diet  may  be  offered  as  giving  a  general  idea  of 
the  regimen  for  somewhat  advanced  cases  : 

Breakfast. — Bread  and  milk  or  well-cooked  oatmeal  porridge  or 
wheaten  grits  without  sugar  (lemon  juice  may  be  added  instead). 
A  chop  or  a  little  broiled  fresh  fish,  coffee  without  sugar. 

Dinner  (not  later  than  2  p.  m.). — Beef  or  mutton,  bread,  one  or 


THE   RESPIRATORY   SYSTEM. 


445 


two  green  or  succulent  vegetables,  such  as  spinach,  stewed  celery, 
stewed  or  raw  tomatoes.  Blancmange  or  custard  (not  sweetened), 
or  a  little  rice  pudding.  Fresh  fruit  in  season,  such  as  a  peach  or 
baked  apple. 

Supper  (6  p.  m.). — A  soft-cooked  t%g  or  a  little  cold  fowl  or 
game,  stale  bread,  toast,  or  Zwieback,  milk,  stewed  fruit  (without 
sugar). 

Patients  should  eat  very  moderately,  masticate  thoroughly,  and 
take  their  meals  with  punctuality. 

Among  beverages,  coffee  without  sugar  is  better  borne  than  tea. 
Loomis  believed  that  "  not  infrequently  a  paroxysm  of  asthma  can 
be  warded  off  by  taking  two  or  three  cups  of  strong  coffee  immedi- 
ately upon  the  accession  of  the  first  asthmatic  symptom." 

During  an  attack  non-alcoholic  patients  may  take  a  hot  strong 
lemonade  with  whisky  or  a  hot  brandy  and  soda.  Malt  liquors  are 
forbidden. 

Emphysema. 

Patients  suffering  from  emphysema  have  more  or  less  engorge- 
ment of  the  venous  circulation,  and  hence  are  liable  to  catarrh  of  the 
stomach  and  intestines.  The  dyspnoea  from  which  they  suffer  on 
exertion  is  considerably  aggravated  by  flatulency,  and  their  diet 
must  be  regulated  to  prevent  this  occurrence.  In  general,  starchy 
and  saccharine  foods  are  to  be  avoided  as  constipation  must  be 
prevented.  For  a  discussion  of  these  principles,  the  reader  is  re- 
ferred to  the  articles  upon  Gastric  Dyspepsia  and  Constipation, 

The  patient  must  be  particularly  warned  against  too  rapid  eating 
and  overeating.  Condiments,  sauces,  fried  and  greasy  food,  and 
all  obviously  indigestible  articles,  must  be  shunned.  Fluids  should 
not  be  taken  with  solid  food,  and  should  be  used  in  moderation. 
Water  may  be  drunk  an  hour  before  meals,  but  not  for  three  hours 
after.  In  the  early  stages  a  nourishing  diet,  consisting  chiefly  of 
animal  food,  meat,  fish,  milk,  cream,  eggs,  and  good  butter,  .should 
be  taken.  If  dyspnoea  predominates  with  frequent  asthmatic  at- 
tacks, it  will  be  best  to  substitute  milk  largely  for  other  foods,  and 
in  the  later  stages,  with  a  feeble  heart  and  increasing  congestion  of 
the  abdominal  viscera,  the  diet  should  consist  wholly  of  milk  and 
meat  broths.     Cod-liver  oil  is  an  excellent  food  in  emphysema. 

Pneumonia. 

Symptoms. — Pneumonia  is  an  infectious  inflammatory  disease 
of  the  lungs,  accompanied  by  grave  constitutional  disturbances,  such 
as  fever  and  rapid  and  enfeebled  heart  action.  The  mortality  at 
some  seasons  of  the  year,  and  especially  among  debilitated  or  alco- 
holic patients,  is  very  great,  and  since  no  known  remedy  can  limit 


^6  DIET    IN   DISEASE. 

the  disease,  it  is  exceedingly  important  to  maintain  the  strength  of 
the  patient  through  the  fev/  days  during  which  the  fever  lasts,  or 
until  the  crisis  by  which  it  terminates  has  been  reached.  All  danger, 
however,  is  not  then  over,  and  convalescence  in  all  cases,  and  espe- 
cially in  aged  persons,  must  be  promoted  by  careful  dietetic  treat- 
ment. The  onset  of  the  disease  is  acute,  and  the  fever  is  often 
high,  reaching  104°  or  105°  or  more  on  the  first  day.  The  duration 
of  the  fever  varies  from  five  to  seven  or  nine  days  on  the  average, 
when  it  subsides  by  a  sudden  fall.  The  rate  of  respiration  is  greatly 
accelerated,  with  or  without  subjective  dyspnoea.  More  or  less 
cough  accompanies  the  fever,  and  there  is  frequently  delirium. 

Dietetic  Treatment. — The  indications  for  treatment  are  to 
give  a  light  diet,  which  will  not  excite  the  cough  in  swallowing  or 
increase  dyspnoea  by  distention  of  the  stomach,  or  augment  the  en- 
feeblement  of  the  heart  action  by  overtaxing  the  digestive  powers. 
Vomiting  should  be  especially  guarded  against,  and  if  nausea  exists, 
efforts  should  be  made  at  once  to  control  it.  It  is  not  necessary  to 
keep  the  patient  upon  a  rigid  milk  diet,  but  if  milk  is  well  borne,  it 
is  advisable  to  give  nothing  else  while  the  acute  symptoms  last; 
otherwise,  milk,  whey,  meat  juice,  broths,  and  egg  albumen  may  be 
allowed.  Starchy  and  saccharine  food  must  be  withheld.  Cold 
drinks  are  both  acceptable  and  beneficial  to  the  patient,  and  water, 
plain  or  aerated,  such  as  ApoUinaris  or  soda  water,  may  be  drunk  in 
considerable  quantity.  It  is  believed  by  some  authorities  that  the 
activity  of  the  kidneys  may  be  thus  promoted,  and  that  the  poison 
which  occasions  the  constitutional  symptoms  of  the  disease  may  be 
better  eliminated.  There  are  cases,  however,  among  persons  with 
robust  circulation  in  which  the  onset  is  very  sudden  and  violent. 
The  pulse  is  full  and  bounding,  and  the  heart  is  greatly  overworked 
by  the  effort  to  propel  a  large  volume  of  imperfectly  aerated  blood. 
In  such  instances  the  addition  of  large  quantities  of  fluid  to  the  cir- 
culation, besides  what  is  actually  required  for  nutrition,  may  have 
the  effect  of  still  further  straining  the  heart. 

It  is  stated  that  carbonated  waters  reduce  the  viscidity  of  the 
sputum,  which  is  often  very  tenacious. 

The  diet  should  be  kept  fluid  until  defervescence  has  occurred, 
with  a  normal  temperature  and  commencing  disappearance  of  the  ex- 
udation— in  fact,  it  is  well  to  prolong  the  fluid  diet  for  three  or  four 
days  after  the  temperature  has  become  normal,  in  order  to  make 
sure  that  a  relapse  of  the  fever  is  not  likely  to  follow.  In  those 
cases  in  which  resolution  is  postponed  and  the  patient  becomes 
more  and  more  feeble,  although  the  temperature  may  be  nearly  or 
quite  normal,  it  may  be  desirable  to  give  a  little  properly  prepared 
solid  food  somewhat  earlier,  and  scraped  beef,  milk  toast,  or  a  soft 
cooked  egg  may  be  added  to  the  milk  diet. 


THE   RESPIRATORY   SYSTEM.  447 

During  the  entire  period  of  convalescence  the  diet  must  be  very 
nourishing  and  of  easy  digestion  ;  milk  may  still  be  given,  and  after 
slowly  returning  to  the  regulation  three  meals  a  day  (see  Convales- 
cent Diet,  page  395)  patients  do  well  to  take  milk  punch,  or  egg- 
nog,  or  a  glass  of  wine  and  a  biscuit  three  or  four  times  a  day  in 
the  intervals. 

Aicoholis  exceptionally  well  borne,  and  it  undoubtedly  serves  both 
as  a  food  and  as  a  support  to  the  overworked  heart.  The  fact  that 
it  is  thoroughly  oxidised  in  the  circulation  or  tissues  is  demonstrated 
by  the  large  quantities  which  patients  can  often  digest  and  absorb 
without  toxic  symptoms.  Doses  may  be  thus  tolerated  which  in 
health  would  ordinarily  produce  drunkenness.  In  alcoholic  subjects 
who  have  been  drinking  up  to  the  time  of  the  onset  of  the  disease  it 
is  indispensable  to  continue  the  use  of  alcohol,  for  the  sudden  with- 
drawal of  its  stimulating  effect  on  the  organism  may  give  rise  to 
rapid  collapse.  In  aged  and  constitutionally  weak  persons  it  is  also 
important  that  its  use  should  be  begun  early  in  considerable  quan- 
tities. 

In  extreme  cases  as  much  as  an  ounce  an  hour,  or  twenty-four 
ounces  in  the  day,  may  be  given  with  benefit,  but  ordinarily  from 
eight  to  ten  ounces  will  suffice.  There  are  other  cases  found  among 
robust  subjects  who  do  not  need  such  stimulation,  and  possibly  may 
not  require  alcohol  at  all.  The  custom  now  in  vogue  of  prescribing 
other  forms  of  cardiac  stimulants,  such  as  strychnine  and  aconite, 
and  vaso-dilators,  like  nitroglycerin,  makes  the  employment  of  ex- 
cessive doses  of  alcohol  less  imperative.  It  should  always  be  re- 
membered that  it  is  undesirable  to  produce  toxic  symptoms  of  alco- 
holism in  pneumonia  as  well  as  in  any  other  disease.  So  long  as  the 
pulse  is  slowed  and  its  force  strengthened  the  use  of  alcohol  may 
be  regarded  as  beneficial ;  but  if  delirium  is  increased  and  the  odour 
of  whisky  or  brandy  is  strong  in  the  breath  an  hour  or  two  after  it 
has  been  given,  it  is  an  indication  that  the  patient  is  receiving  more 
than  is  desirable,  and  the  dosage  should  be  reduced.  From  its  serv- 
ing as  a  fuel,  and  thereby  saving  tissue  waste  in  the  muscles,  the  free 
use  of  alcohol  in  pneumonia  undoubtedly  saves  many  lives. 

Broncho-Pneumonia. 

Symptoms. — Broncho-pneumonia  is  an  inflammation  of  the  cap- 
illary bronchi  which  extends  to  the  lobular  structures.  It  is  common 
in  the  extremes  of  age,  in  the  very  old  and  very  young.  The  mor- 
tality is  greatest  in  children  under  two  years  of  age.  It  is  the  se- 
quel to  many  of  the  acute  diseases  of  childhood,  and  is  also  pro- 
duced by  the  tubercle  bacillus  and  by  the  inspiration  of  particles  of 
food  or  fluid  which  are  drawn  through  the  larynx  to  the  bronchi  by: 
inhalation  during  the  act  of  swallowing.  The  latter  variety  may- 
Si 


448 


DIET   IN   DISEASE. 


occur  as  a  result  of  drawing  seeds  or  other  hard  substances  into  the 
bronchi;  from  operations  about  the  mouth  and  upper  air  passages 
after  tracheotomy ;  and  from  the  conditions  which  impair  the  nor- 
mal sensitiveness  of  the  larynx  and  the  reflex  action  of  the  epiglot- 
tis and  vocal  cords,  such  as  profound  uraemia  or  apoplectic  or  alco- 
holic coma,  and  post-diphtheritic  or  laryngeal  paralysis.  A  few 
cases  have  been  produced  by  carelessness  in  the  passing  of  the 
oesophageal  catheter  into  the  larynx  and  pouring  liquid  food  into  it. 
Dietetic  Treatment. — Broncho-pneumonia  is  always  a  very 
critical  disease  and  the  utmost  care  is  required  in  nursing  and  feed- 
ing. The  diet  should  consist  of  such  articles  as  meat  juice,  predi- 
gested  milk,  and  egg  albumen.  Stimulation  is  early  required  and  in 
considerable  quantity.  Brandy  or  whisky  sweetened  with  a  little 
sugar  and  cold  water  should  be  systematically  given,  especially  to 
young  children,  who  are  unable  to  make  their  want  of  drink  known. 
Hot  milk  and  Vichy,  in  the  proportion  of  one  part  of  Vichy  to  two 
of  milk  for  older  children,  or  half-and-half  for  young  infants,  may 
have  the  effect  of  loosening  the  tenacious  mucus  and  easing  the 
cough.  If  there  is  any  tendency  to  flatulency,  aerated  waters  had 
better  be  avoided. 

BRONCHO-PNEUMONIA  IN  CHILDREN. 

The  diet  should  be  adapted  to  foster  the  strength  and  tax  the 
digestive  organs  as  little  as  possible.  At  first  food  should  be  given 
every  two  hours,  and  milk  is  usually  all  that  is  required.  Later  it 
may  be  alternated  with  or  supplemented  by  egg  albumen,  expressed 
meat  juice,  plain  beef  or  mutton  broths,  arrowroot,  or  other  gruels. 

Brandy  is  the  best  alcoholic  food  and  stimulant,  and  it  may  be 
ordered  in  doses  of  from  ten  drops  to  a  teaspoonful  well  diluted  with 
water,  Vichy,  milk,  or  egg-albumen  solution.  In  very  bad  cases  a 
child  a  year  old  should  be  given  one  to  two  ounces,  and  a  child  two 
or  three  years  of  age  four  to  six  ounces  in  twenty-four  hours. 

Pleurisy. 

Of  the  various  forms  of  pleurisy,  those  which  are  chiefly  influ- 
enced by  diet  are  pleurisy  with  effusion  and  empyema.  In  pleurisy 
with  effusion  the  objects  to  be  attained  are  to  preserve  the  strength 
of  the  patient  and  promote  the  reabsorption  of  the  fluid  in  the  pleu- 
ral sac.  A  diet  is  therefore  advised  which  shall  consist  of  nutritious 
solids  with  a  minimum  amount  of  fluid,  in  order  that  the  blood  may 
become  more  dense  and  that  favourable  osmosis  may  occur  from 
the  pleuritic  cavity  into  the  blood  vessels:  at  the  same  time  free 
action  of  the  kidneys  should  be  promoted.  To  still  further  favour 
the  absorption  of  fluid,  a  special  dry  diet  has  been  recommended  in 
which,  as  in  case  of  aneurism,  the  patient  is  encouraged  to  take  as 


THE  RESPIRATORY  SYSTEM. 


449 


little  fluid  as  possible  and  to  eat  quantities  of  table  salt  by  the  tea- 
spoonful,  the  idea  being  to  increase  the  density  of  the  blood  both 
by  withholding  fluid  and  adding  salt,  and  that  the  latter  may  also 
promote  osmosis.  This  treatment  has  been  attempted  in  several  of 
the  New  York  hospitals  and  elsewhere,  but  has  not  met  with  suc- 
cess, mainly,  no  doubt,  on  account  of  the  difficulty  of  overcoming 
the  thirst  of  the  patient,  which  is  doubly  aggravated  by  the  lack  of 
fluid  and  the  supply  of  salt. 

An  extreme  dry  diet  known  in  Germany  as  "  Schroth's  Method  " 
has  been  indorsed  by  Niemeyer,  Pimser,  and  others.  The  patient 
is  fed  upon  lean  roast  veal  and  stale  rolls  {Butterbrod)  without 
fluid  of  any  kind  but  a  little  water  until  the  third  day,  when  half  a 
pint  of  red  wine  is  given.  At  the  end  of  a  week  a  pint  is  allowed. 
Very  few  patients  will  submit  to  such  treatment  in  this  country,  and 
it  certainly  is  severe.  A  reasonable  abstinence  from  fluids,  especially 
water,  is  all  that  can  be  expected.  Practically,  many  patients  are 
found  to  go  on  reabsorbing  pleuritic  exudation  while  continuing  a 
milk  or  other  fluid  diet  which  is  necessitated  by  some  complication 
in  the  digestive  system. 

Several  French  writers,  as  Serre  and  Eloy,  advocate  an  exclusive 
milk  diet,  giving  from  three  pints  to  three  quarts  daily,  to  be  sipped 
in  small  quantities  every  hour  or  two.  They  rely  upon  the  diuretic 
effect  of  the  milk,  and  give  it  in  any  form  most  agreeable  to  the 
patient.  The  treatment  is  continued  for  a  week  or  more  after  the 
exudation  has  been  absorbed,  and  return  to  a  solid  diet  must  be 
gradual. 

This  method  is  obviously  directly  opposed  to  the  dry  diet,  and 
possesses  no  advantages  over  it,  excepting  sometimes  in  cases  com- 
plicated by  chronic  valvular  heart  disease,  gastric  catarrh,  or  ad- 
vanced anaemia.  In  England  and  Europe  thoracentesis  appears  to 
be  much  less  practised  than  in  this  country,  where  it  is  performed 
with  but  little  hesitation. 

If  the  pleuritic  exudation  accumulates  in  sufficient  quantity  to 
severely  embarrass  respiration  or  the  action  of  the  heart,  it  is  so 
easy  to  absolutely  withdraw  it  by  the  aspiration  needle  when  anti- 
septic precautions  are  taken  that  annoying  the  patient  by  experi- 
mental dietetics  is  hardly  justifiable,  and  I  have  found  solid  diet 
with  reasonable  restriction  to  be,  on  the  whole,  the  most  satisfac- 
tory. Patients  who  are  fairly  robust  will  naturally  endure  privation 
of  food  and  drink  better  than  the  feeble  and  anaemic. 

Empyema. 

The  dietetic  treatment  of  empyema  is  based  upon  the  need  for 
nutrition  to  supply  the  drain  on  the  system  of  the  constant  excretioh 
of  pus,  and  fatty  food,  such  as  butter,  cod-Kver  oil,  and  cream  should 


i-Q  DIET   IN  DISEASE. 

therefore  fill  a  large  portion  of  the  dietary.  The  general  supporting 
treatment  prescribed  for  the  early  stages  of  pulmonary  tubercu- 
losis is  recommended  (page  434). 


DIET   IN    DISEASES   OF   THE   CIRCULATORY   SYSTEM 

AND    BLOOD. 

Diseases  of  the  Heart. 

The  proper  dietetic  treatment  of  advanced  heart  disease  deserves 
careful  consideration,  for  on  it  to  a  great  extent  depends  the  pa- 
tient's comfort,  if  not  the  prolongation  of  his  life.  It  cannot  be  said 
that  the  several  conditions  of  cardiac  enlargement,  valvular  disease, 
fatty  degeneration,  etc.,  demand  different  forms  of  treatment  per  se, 
but  there  are  certain  general  principles  which  should  be  observed  in 
any  case  when  particular  symptoms  arise.  The  dietetics  of  cardiac 
diseases  may,  accordingly,  be  conveniently  reviewed  together. 

Pathological  Physiology. — The  general  conditions  involved  are 
largely  physical,  or  rather  mechanical — perhaps  more  so  than  in  any 
other  form  of  disease. 

1.  We  have  to  deal  with  a  pump  whose  action  is  impaired  by 
more  or  less  weakness  of  its  walls,  or  leakage  or  obstruction  of  its 
•valves,  or  which  is  overworked  by  the  imposition  of  increased  re- 
isistance. 

2.  The  balance  of  food  pressure  in  the  vessels  is  usually  disturbed 
and  the  rate  of  blood  flow  is  altered. 

3.  As  the  disproportion  increases  between  the  driving  force  or 
the  resistance  of  the  vessels  and  the  volume  of  the  fluid  to  be  pro- 
pelled, there  is  apt  to  be  leakage  of  serum  in  various  situations, 
producing  dropsies  or  general  anasarca.  Or  these  conditions  may 
result  from  a  diminution  in  the  vitality  of  the  peripheral  blood  ves- 
sels or  changes  in  the  composition  of  the  blood  itself. 

4.  The  rate  of  absorption  of  the  materia  alimentaria  by  osmosis 
depends  as  much  upon  the  activity  of  the  circulation — i.  e.,  upon  the 
rapidity  of  renewal  of  the  layer  of  blood  in  the  capillaries  of  the  ab- 
sorbing surface — as  upon  the  density  and  composition  of  the  blood, 
the  action  of  individual  cells,  or  any  other  factor.  A  feebly  beating 
heart  or  an  obstructed  vascular  system  promptly  checks  absorption. 
Moreover,  the  reabsorption  of  transudated  serum  will  depend  upon 
the  reversal  of  the  conditions  which  originally  caused  it. 

5.  The  elimination  of  waste  and  the  various  processes  of  secre- 
tion depend  upon  almost  identical  conditions  with  absorption,  and 
while  not  due  merely  to  filtration,  they  are  nevertheless  controlled 
very  promptly  by  alterations  in  blood  pressure  and  in  the  velocity  of 
the  current. 


THE   CIRCUL'ATORY   SYSTEM   AND   BLOOD. 


451 


Bearing  in  mind  these  elementary  principles,  the  first  question 
which  arises  in  the  dietetic  treatment  of  advanced  cardiac  disease 
must  concern  the  administration  of — 

Fluids. — An  additional  pint  of  fluid  beyond  the  needs  of  the 
system  may  be  just  sufficient  to  overtax  the  heart,  alter  the  balance 
of  blood  pressure,  disturb  a  temporary  compensation,  and  precipi- 
tate anasarca,  renal  congestion,  pulmonary  oedema,  or  other  symp- 
toms. 

On  the  other  hand,  with  too  little  fluid  the  blood  pressure  may 
fall  to  a  dangerous  degree  or  there  may  not  be  water  enough  in  the 
vascular  system  to  maintain  the  free  diuretic  action  which  is  so  de- 
sirable. It  is  a  well-known  physiological  fact  that  the  heart,  like 
any  other  muscle,  does  better  work  if  it  has  reasonable  resistance  to 
overcome.  Such  are  the  problems,  briefly  stated,  which  must  be 
met,  not  by  the  enforcing  of  text-book  rules,  but  by  the  frequent 
examination  of  the  peculiarities  of  each  case,  by  the  comparison 
from  day  to  day  of  the  amount  and  quality  of  the  urine,  the  degree 
of  arterial  tension,  the  force  of  the  heart  beat,  and  the  possible  pres- 
ence of  oedema. 

Dietetic  Treatment. — It  is  difficult  to  formulate  any  but  the 
most  general  rules  for  the  dietetic  treatment  of  chronic  valvular 
disease  of  the  heart.  These  cases  often  extend  through  a  period  of 
many  years,  and  the  variety  of  secondary  symptoms  which  may  ap- 
pear is  very  great.  The  forms  of  valvular  disease  which  are  most 
apt  to  result  in  disturbances  of  digestion  are  those  in  which  ob- 
structed venous  circulation  results  in  local  engorgement  of  the  ab- 
dominal viscera,  producing  nausea,  vomiting,  and  great  distaste  for 
food.  Constipation  and  more  or  less  chronic  gastric  and  intestinal 
catarrh  may  be  among  the  symptoms.  The  hypostatic  congestion 
of  the  liver  retards  the  activity  of  that  organ,  and  the  ingredients  of 
the  food  which  ar-e  brought  to  it  by  the  portal  system  are  no  longer 
properly  elaborated,  so  that  general  nutrition  and  assimilation  suffer 
in  consequence.  A  depleting  diet  is,  therefore,  sometimes  to  be  rec- 
ommended, and  concentrated  food  is  required  to  prevent  over- 
burdening the  circulation.  If  gastric  catarrh  necessitates  the  use  of 
fluid  food,  the  quantity  of  beverages  taken  in  addition  should  be 
considerably  restricted.  When  acute  attacks  of  indigestion  super- 
vene in  the  course  of  chronic  valvular  disease,  the  bowels  should  be 
kept  thoroughly  open,  and  a  diet  of  milk,  beaten  eggs,  and  broths, 
taken  once  in  three  hours,  mus^-be  prescribed  for  a  few  days,  after 
which  boiled  fish,  broiled  chicken,  scraped  beef,  beefsteak,  or  rare 
roast  beef  may  be  added.  Fats,  farinaceous  foods,  and  sugars 
should  not  be  allowed,  owing  to  their  tendency  to  produce  flatu- 
lency and  aggravate  existing  symptoms.  The  use  of  alcoholic  stimu- 
lation may  at  times  become  necessary,  and  whisky  diluted  in  some 


j^  DIET    IN   DISEASE. 

non-effervescing  water  is  perhaps  the  best.  Beer  should  be  particu- 
larly avoided,  and  recommendation  of  the  regular  use  of  stimulants, 
in  this  as  in  other  forms  of  chronic  disease,  should  be  made  with 
great  caution  lest  the  alcoholic  habit  be  acquired  and  become  per- 
manent. Patients  with  sudden  cardiac  dilatation,  such  as  sometimes 
occurs  during  convalescence  from  typhoid  fever,  need  to  return  to  a 
milk  diet. 

When  acute  symptoms  of  palpitation,  dyspnoea,  etc.,  develop,  the 
patient  should  never  eat  very  much  food  at  one  time.  It  is  better  to 
take  four  or  five  meals  a  day,  if  necessary,  and  eat  only  small  quan- 
tities. A  large  meal  always  distends  the  stomach  considerably  for 
several  hours,  causing  this  organ  to  elevate  the  diaphragm  and  dis- 
place somewhat  the  heart,  which  lies  upon  it,  and  diminishing  the 
vertical  diameter  of  the  chest.  The  heart  may  become  irritated  by 
the  mechanical  pressure  to  which  it  is  subjected  by  a  moderate  de- 
gree of  displacement,  and  it  is  indirectly  affected  by  the  greater  dif- 
ficulty of  breathing,  as  well  as  by  reflex  irritation  from  the  disor- 
dered stomach.  All  food  which  is  liable  to  ferment  in  the  stom- 
ach, such  as  sugar  and  indigestible  starches  and  fats,  must  be  par- 
ticularly avoided.  Gastric  catarrh  is  readily  excited  and  aggravated 
by  coarse  or  fermenting  food.  On  this  account  also  the  use  of  strong 
alcohol  should  be  forbidden  except  in  the  case  of  aged  and  feeble 
persons,  to  whom  light  wine  or  diluted  spirits  may  be  given.  The 
regular  use  of  tobacco  should  be  prohibited,  and  tea  and  coffee,  if 
permissible,  are  to  be  taken  only  in  very  dilute  form.  The  tendency 
to  constipation  can  be  overcome  by  attention  to  diet  and  a  moderate 
amount  of  fruit  such  as  baked  or  stewed  apples,  stewed  prunes,  and 
grape  fruit  may  be  allowed  between  meals. 

CARDIAC  VALVULAR  DISEASE  IN  CHILDREN. 
Children  who  have  chronic  valvular  disease  or  enlargement  of 
the  heart,  but  who  are  not  strictly  confined  to  bed,  should  be  closely 
supervised  in  regard  to  their  habits  of  eating.  They  should  eat 
slowly  and  moderately,  and  have  their  meals  at  regular  intervals, 
taking  the  principal  meal  at  noon,  and  a  light  supper  two  hours  be- 
fore bedtime.  In  general,  animal  food  is  better  for  them  than  vege- 
tables, but  they  may  eat  the  lighter  fresh  vegetables,  such  as  spinach, 
tomatoes,  or  stewed  celery  in  season,  and  sometimes  a  little  roast  or 
mashed  potato.  Rice  and  macaroni  may  be  given.  Bread  should 
be  only  eaten  dry  or  toasted.  Sweets  should  not  be  allowed,  except 
very  rarely,  when  a  taste  of  jam  or  preserves  may  be  given.  Such 
substances  are  apt  to  cause  flatulency  and  palpitation,  if  not  more 
serious  disturbances,  and  everything  depends  upon  saving  the  heart 
from  excitation  or  strain.  All  food  should  be  very  simply  cooked, 
and  too  great  variety  is  harmful.  . 


THE   CIRCULATORY   SYSTEM   AND   BLOOD. 


453 


In  acute  disease  of  the  valves — such,  for  instance,  as  that  pro- 
ducing mitral  regurgitation — it  is  very  important  to  avoid  all  food 
likely  to  cause  dyspepsia.  Raw  eggs  with  brandy,  broths,  and 
chiefly  milk  must  be  prescribed,  and  if  the  stomach  is  weak  and  irri- 
table, a  part  of  the  nutriment  may  be  given /^r  rectum  (page  380). 

DIETETIC    TREATMENT   OF   THE   SENILE    HEART. 

In  persons  past  middle  life  the  heart  may  become  enfeebled  from 
a  variety  of  causes  independent  of  inflammatory  conditions  or  val- 
vular lesions.  Fatty  degeneration  is  a  very  common  cause  of  such 
weakness,  and  in  other  cases  the  hearty  muscle  may  gradually  lose 
its  normal  strength  and  "  tone  "  from  strain,  or  a  disturbance  of  bal- 
ance between  its  power  and  the  peripheral  resistance  to  be  overcome. 
In  the  aged  the  arterial  walls  become  less  and  less  resilient,  if  not 
actually  rigid,  from  calcareous  deposit,  and,  moreover,  the  heart 
suffers  no  less  than  other  organs  from  impaired  nutrition.  In  such 
cases  the  prolongation  of  the  patient's  life  as  well  as  the  mainte- 
nance of  his  comfort  may  be  fostered  by  attention  to  dietetics. 

A  weak  heart  implies  impaired  circulation  in  the  gastric  vessels, 
and  hence  the  gastric  juice  becomes  poor  in  quality  and  lessened  in 
quantity.  Digestion  is  consequently  retarded,  and  absorption  of 
food  products  is  less  active  than  it  should  be.  The  heart  and  the 
stomach  being  both  supplied  by  branches  of  the  vagus  nerve,  it  is' 
easy  to  understand  how  gastric  irritation,  caused  by  products  of  mal- 
fermentation,  organic  acids,  accumulated  undigested  food,  or  gaseous 
distention,  may  affect  the  heart  through  reflex  action.  Mechanically, 
too,  a  stomach  distended  by  gas  presses  upon  and  irritates  the 
heart.  Balfour  (The  Senile  Heart,  1894)  says:  "If  the  heart  is 
weak  the  discomfort  induced  by  such  irregularities  is  after  middle 
life  more  apt  to  be  felt  in  connection  with  that  organ  than  in  the 
stomach  itself."  The  result  is  intermission  in  the  pulse  rate,  un- 
evenness  in  force  and  frequency  of  the  heart  beat,  its  "  fluttering" 
action,  and  sensations  of  palpitation,  praecordial  distress,  fulness  or 
constriction,  and  dyspnoea.  In  order  to  avoid  these  symptoms  as 
far  as  possible,  the  patient  must  have  his  diet  carefully  supervised. 
A  sufficient  interval — fully  five  hours — must  always  elapse  for  the 
complete  digestion  of  one  meal  before  a  second  is  taken,  and  because 
the  gastric  juice  is  feeble  it  is  best  not  to  allow  more  than  four 
or  five  ounces  of  fluid  of  any  kind  to  be  taken  with  the  meals. 
While  sufficient  variety  of  food  may  be  allowed  to  maintain  a  fair 
appetite,  it  should  never  be  so  great  as  to  entice  the  patient  to  eat 
too  freely. 

Balfour  summarises  excellent  rules  for  dieting  to  be  followed  by 
patients  whose  cardiac  action  is  enfeebled  by  any  cause,  but  espe- 
cially for  the  condition  described  as  "the  senile  heart." 


.^  .DIET   IN   DISEASE. 

Balfour's  Rules  for  dieting  for  Weak  Hearts. 
'•  I.  There  must  never  be  less  than  five-hour  intervals  between 
meals. 

"  2.  No  solid  food  is  ever  to  be  taken  between  meals. 
"  3.  All  those  with  weak  hearts  should  have  their  principal  meal 
in  the  middle  of  the  day. 

"4.  All  those  with  weak  hearts  should  have  their  food  as  dry  as 
possible." 
"    A  good  typical  ttienu  is  given  by  the  writer  above  quoted : 

Balfour  s  Diet  for  the  Senile  Heart. 

^^  Breakfast,  S.^o  A.  y[. — Dry  toast,  one  small  piece — one  or  one 
and  a  half  ounce — with  butter;  one  soft,  boiled  egg,  a  small  piece  of 
whitefish ;  three  to  five  ounces  of  tea  or  coffee  with  cream  and 
sugar,  or  an  infusion  of  cocoa  nibs,  or  milk  and  hot  water,  or  cream 
and  Seltzer.  Sometimes  oatmeal  porridge  is  permissible,  but  not 
over  three  or  four  ounces  should  be  taken. 

^'  Principal  Meal,  1.30  or  2  p.  m. — Fish,  such  as  haddock  or  sole,  or 
meat  and  pudding.  Two  courses  only  are  allowed.  No  soups, 
pickles,  pastry,  or  cheese.  Whitefish  and  short-fibred  meat  only 
are  allowable.  The  fish  may  be  boiled  in  milk.  A  little  spinach  or 
one  potato  may  sometimes  be  eaten,  or  a  half  pound  of  fruit,  such 
as  pears,  apples,  or  grapes.  Four  to  five  ounces  of  hot  water  may 
be  drunk  with  each  meal,  but  no  more. 

"  $  to  6  p.  M. — Three  to  four  ounces  of  tea  (one  teacupful)  infused 
for  four  minutes  may  be  drunk,  but  absolutely  no  solid  food  is  to  be 
taken  with  it.  If  desirable,  a  teaspoonful  of  Liebig's  extract  of 
meat  may  be  stirred  in  with  the  tea. 

"  Supper,  7  p.  M. — Whitefish  and  a  potato  or  toast  and  pudding,  or 
milk  pudding,  or  bread  and  milk,  or  revalenta  made  with  milk  or 
Liebig's  extract. 

"  Bedtime. — Four  to  five  ounces  of  very  hot  water,  sipped,  helps;" 
the  patient  to  fall  asleep." 

Upon  this  very  Hmited  regimen  the  patient,  if  heavy  and  water-., 
logged,  at  first  loses  weight  by  absorption  of  "  oedematous  soakage,"- 
or  if  much  wasted  he  may  gain  in  weight.     In  this  manner  the  natu- 
ral equilibrium  of  the  body  is  re-established. 

In  not  too  critical  cases  a  little  more  latitude  is  permitted,  and 
such  vegetables  may  be  occasionally  eaten  as  asparagus,  onions, 
leeks,  tomatoes,  lettuce,  cress.  The  heavier,  coarser  vegetables  (like 
cabbage,  sprouts,  turnips,  parsnips,  carrots,  beets,  legumes),  pastry, 
nuts,  dried  fruits,  and  sweets  of  all  kinds  are  forbidden. 

Equal  care  must  be  given  to  the  selection  of  proper  beverages.  - 
If  there  is  much  palpitation,  tea,  coffee,  and  chocolate  must  be  pro-; 
scribed.     In  many  cases  Balfour  allows  a  little  weak  tea,  made  by. , 


THE   CIRCULATORY   SYSTEM   AND   BLOOD. 


455 


infusing  a  teaspoonful  (about  one  hundred  grains)  in  four  or  five 
ounces  of  water  for  only  three  or  four  minutes.  Alcathrepta  may 
be  drunk.  The  two  latter  beverages  may  be  taken  at  5  p.  m.  or  on 
retiring,  when  the  stomach  is  empty.  They  must  not  be  made  too 
sweet. 

No  champagne  or  effervescing  drinks  are  allowed,  and  all  alco- 
holic beverages  should  be  given  only  in  moderation.  If  more  than 
two  ounces  (a  claret-glass  full)  of  one  of  the  stronger  wines  is  taken, 
it  excites  acid  dyspepsia,  and  claret.  Burgundy,  or  hock  should  not 
be  allowed  in  greater  measure.  A  small  glass  of  port  or  sherry  may 
be  drunk  twice  a  day ;  but,  as  Balfour  observes,  there  is  so  much 
idiosyncrasy  in  the  digestibility  of  wines  that  in  general  plain  liquor 
is  better  for  these  cases  and  in  the  small  quantity  recommended  in 
the  menu  given  above.  Alcohol  is  by  no  means  a  necessity,  ^nd 
many  patients  are  better  without  any.  He  has  great  faith  in  the 
stimulating  properties  of  hot  water,  slowly  sipped,  and  says :  "  This 
will  be  found  to  have  quite  as  good  an  immediate  effect  upon  the 
heart  as  alcohol." 

It  has  been  elsewhere  shown  that  the  frequent  acts  of  degluti- 
tion performed  in  sipping  any  fluid  tend  to  increase  the  pulse  rate 
slightly  through  reflex  stimulation  of  the  vagus  branches  which 
are  concerned  in  the  act. 

As  the  heart  becomes  more  and  more  feeble,  the  inactive  circula- 
tion, perhaps  aided  by  alteration  in  the  composition  of  the  blood  or 
by  albuminuria,  results  in  the  production  of  localised  oedema  or  gen- 
eral anasarca. 

In  referring  to  the  use  of  dry  diet  for  these  conditions  as  occur- 
ring in  connection  with  the  senile  heart,  Balfour  says:  "When  there 
is  anasarca,  or  any  evidence  of  soakage  in  any  dependent  part  of 
the  body,  it  is  of  the  greatest  importance  to  place  the  patient,  for 
a  time  at  least,  on  the  driest  possible  diet,  and  not  too  much  of 
it.  ...  I  have  seen  a  considerable  amount  of  oedema  of  the  lower 
limbs  disappear  within  twenty-four  hours  before  there  had  been 
time  for  any  change  in  the  heart,  which  was  feeble  and  dilated." 
His  dry  diet  is  as  follows: 

Breakfast.— ^.  single  slice  of  dry  toast,  without  butter.  A  cup  of 
tea  (infused  only  four  minutes). 

Dinner. — The  lean  of  two  chops,  or  their  equivalent  in  chicken  or 
fish.  No  vegetables.  Dry  toast  adlibitum.  Half  an  ounce  of  brandy, 
whisky,  or  Hollands  in  three  ounces  of  water. 

Supper. — As  much  dry  toast  as  desired.  Half  an  ounce  of  liquor, 
as  at  dinner. 

Nothing  else  is  allowed ;  but  if  the  patient  is  thirsty,  very  hot 
water  may  be  sipped  between  meals.  This,  Balfour  maintains,  is  an 
excellent  cardiac  tonic. 


456 


DIET   IN  DISEASE.- 


ANGINA  PECTORIS. 
The  only  indication  to  be  met  in  the  dietetic  treatment  of  angina 
pectoris  is  to  reduce  the  arterial  tension.  A  vegetable  diet  with  re- 
stricted fluids,  and  no  alcohol,  is  to  be  recommended.  These  patients 
often  are  subjects  of  the  gouty  diathesis,  and  the  directions  for  diet 
in  that  condition  are  to  be  observed  (see  Gout). 

CARDIAC  PALPITATION. 
The  dietetic  treatment  of  cardiac  palpitation  is  sufficiently  indi- 
cated under  the  heading  of  Flatulent  Dyspepsia.  Overeating  should 
be  avoided,  as  well  as  all  stimulating  foods  and  beverages.  Tea, 
coffee,  and  tobacco  should  be  forbidden — at  least  temporarily. 
Effervescing  drinks  of  all  kinds,  from  their  tende.ncy  to  produce 
flatulency,  should  also  be  proscribed,  as  well  as  all  sweets  and  much 
starchy  food.     Laxative  foods,  especially  fruits,  will  be  found  useful. 

ARTERIAL   SCLEROSIS. 

In  those  cases  in  which  renal  inadequacy  is  a  pronounced  feature 
it  will  be  well  to  put  the  patient  upon  a  milk  diet  for  several  weeks. 
In  general  a  non-stimulating  diet  is  requisite,  with  a  minimum  of 
butcher's  meat,  and  no  strong  condiments,  richly  cooked  dishes,  or 
alcohol  should  be  allowed. 

ANEURISM. 

•  In  aneurism  of  the  larger  arteries  the  vessel  wall  is  dilated  and 
thinned,  and  rupture  is  liable  to  occur  at  any  time  from  increase 
of  the  blood  pressure  or  obstruction  to  the  circulation  produced  by 
sudden  movement,  or  otherwise.  The  most  favourable  result  of 
treatment  which  can  be  anticipated  is  thickening  of  the  diseased 
vessel  by  the  deposit  of  coagulated  fibrin  from  the  blood.  The  co- 
agulability of  the  blood  varies  with  its  composition,  and  is  favoured 
by  increased  density  of  the  blood  and  by  structural  changes  in. its 
albuminous  ingredients.  To  a  limited  extent  this  process  can  be 
aided  by  diet.  The  object  to  be  attained  in  the  dietetic  treatment 
of  aneurism  is  to  reduce  the  volume,  and  consequently  increase  the 
density  of  the  blood.  The  latter  does  not  necessarily  increase  its 
coagulability,  however.  This  method  of  treatment  was  originally^ 
formulated  by  Bellingham  and  Joliffe  Tufnell,  of  Dublin,  and  it  is 
now  described  by  the  latter's  name.  It  is  only  less  rigid  than  the 
very  old  method  of  Valsalva,  who  gave  half  a  pound  of  pudding 
morning  and  evening,  and  nothing  else — practical  starvation  !  In 
conjunction  with  the  dietetic  treatment  absolute  rest  of  the  patient 
is  enjoined;  he  should  lie  horizontally  in  his  bed,  and  not  be  per- 
mitted to  make  exertion  of  any  kind,  and  mental  strain  and  emotion- 
should  be  carefully  guarded  against.     He  should  be  fed  by  a  nurse, 


THE   CIRCULATORY   SYSTEM  "AND   BLOOD. 


457 


and  not  allowed  to  sit  up  at  any  time.  By  rest  alone  the  rate  of  the 
heart  beat  is  materially  slowed,  and  this  is  favoured  also  by  the  re- 
duced diet.  The  artery,  in  consequence,  is  distended  less  and  less 
often  and  is  submitted  to  less  pressure.  The  exact  treatment  recom- 
mended by  Tufnell  is  as  follows : 

TufnelVs  Diet. 

Breakfast. — Two  ounces  of  bread  with  a  little  butter  and  two 
ounces  of  milk. 

Dinner. — From  two  to  three  ounces  of  meat  without  salt  and 
four  ounces  of  milk ;  for  a  portion  of  the  milk  an  ounce  or  two  of 
claret  may  be  substituted. 

Supper. — The  same  as  the  breakfast. 

This  extremely  rigid  diet  is  apt  to  be  rebelled  against  by  most  pa- 
tients, but  it  serves  as  a  basis  for  the  commencement  of  other  treat- 
ment, and  if  it  be  found  impracticable  to  adhere  to  it,  the  quantity  of 
food  will  have  to  be  slightly  increased.  It  may  be  necessary  to 
double  the  quantity  of  milk  and  increase  the  amount  of  bread  or 
vary  it  with  crackers  or  some  light  form  of  starchy  diet.  The  fluid, 
however,  is  in  all  cases  to  be  restricted  as  much  as  possible.  Pa- 
tients usually  complain  bitterly  of  thirst,  and  while  it  is  more  desir- 
able to  restrict  the  fluids  than  the  solids  in  the  dietary,  the  thirst 
may  be  alleviated  somewhat  by  the  use  of  acidulated  drinks,  such  as 
sour  lemonade,  dilute  phosphoric  acid  in  cinnamon  water,  etc.  The 
danger  which  menaces  the  patient  and  the  object  of  his  treatment 
should  be  clearly  explamed  to  him  and  his  co-operation  secured  in 
the  effort  for  his  relief.  It  is  customary  to  employ  iodide  of  potas- 
sium and  morphine  in  moderation  for  their  sedative  action  upon  the 
circulation  and  the  system  generally.  Many  cases  are  of  syphilitic 
origin,  and  they  are  particularly  benefited  by  the  potassium  iodide. 
Upon  this  reduced  diet  improvement  in  physical  signs  of  the  aneu- 
rism— such  as  diminished  pulsation  and  intensity  of  bruit  and  less- 
ened pain — is  occasionally  quite  decided.  In  favourable  cases  im- 
provement may  be  looked  for  at  the  end  of  a  week,  and  if  the 
dietetic  treatment  is  persisted  in  for  six  weeks,  the  benefit  may  be 
considerable.  Tufnell  himself  reports  several  cases  in  which  the 
aneurismal  sac  became  lined  with  a  thick  coating  of  fibrin. 

There  are  many  cases  of  aneurism  outside  the  province  of  surgi- 
cal treatment  which  are  incapable  of  relief  from  any  diet,  but  the 
method  above  described  is  decidedly  worth  a  trial  in  an  otherwise 
hopeless  condition.  I  have  several  times  known  it  to  produce  con- 
siderable lessening  of  pain,  dyspnoea,  and  other  symptoms,  but  it 
requires  firmness  and  perseverance  to  carry  it  out  successfully.  The 
curative  results  have,  unforturyately,  not  verified  Tufnell's  original 
claims,  and  as  pointed  out  by  Loomis,  if  the  method  is  too  rigidly 


458 


DIET   IN   DISEASE. 


and  too  long  enforced — for  six  or  eight  weeks — an  extreme  degree  of 
anaemia  is  apt  to  occur  and  leave  the  patient  worse  off  than  before. 

If  the  Tufnell  diet  is  not  prescribed,  non-stimulating  food  only 
should  be  allowed,  consisting  chiefly  of  simply  cooked  fresh  vege- 
tables and  fruits,  with  but  little  meat.  Anything  likely  to  produce 
flatulency  or  gastric  dyspepsia  should  be  carefully  avoided,  and 
strong  alcohol  must  be  forbidden. 

Anemia. — Chlorosis. 

Pathological  Physiology. — The  proper  nutrition  of  all  the  tis- 
sues of  the  body  is  directly  dependent  upon  the  quality  of  the  blood 
plasma  and  of  the  amount  of  oxygen  conveyed  by  the  corpuscles. 
A  very  slight  departure  from  the  average  composition  of  these  ele- 
ments will  sooner  or  later  result  in  diminishing  the  nutrition  and 
functional  activity  of  all  the  organs  in  the  body,  notably  those  of  the 
digestive  system. 

Anaemia,  whether  acute  and  due  to  haemorrhage  or  some  acute  dis- 
ease, or  chronic  from  any  cause,  by  depleting  the  cellular  elements  of 
the  blood,  interferes  with  the  proper  oxidation  of  food  after  absorp- 
tion. On  the  other  hand,  a  diet  which  is  insufficient  in  amount  or 
inappropriate  in  quality,  if  long  continued,  is  certain  to  produce  an 
impoverished  condition  of  the  blood  with  a  diminution  in  the  nam- 
ber  of  corpuscles;  hence  there  is  a  double  relation  existing  between 
the  power  of  the  blood  to  insure  complete  absorption  and  metab- 
olism, and  of  the  food  itself  to  maintain  the  normal  balance  of  the 
ingredients  of  the  blood.  Anaemia,  therefore,  demands  special  feed- 
ing, the  basis  of  which  should  be  an  effort  to  restore  as  soon  as  pos- 
sible the  proper  number  of  red  corpuscles  and  the  normal  quantity 
of  other  ingredients  of  the  blood  by  a  diet  which  is  nutritious  and 
abundantly  rich  in  nitrogenous  food  given  in  some  easily  assimilable 
form.  When  proteid  food  is  excluded  from  the  diet  for  some  weeks 
the  haemoglobin  of  the  red  blood-corpuscles  is  considerably  reduced 
in  amount  and  hydraemia  ensues,  but  the  pigment  is  always  in- 
creased  by  an  excess  of  nitrogenous  food. 

Anaemia  and  chlorosis  are  most  common  at  the  age  of  puberty, 
and  immediately  thereafter,  among  young  girls  who  are  growing  or 
who  are  overworked  at  school  or  in  factories  while  beginning  men- 
struation, and  who  are  improperly  fed.  The  diversion  of  consider- 
able nervous  energy  for  other  functions  than  those  of  the  circulation 
at  this  time  may  interfere  somewhat  with  the  nervous  mechanism  of 
digestion  and  absorption.  In  other  cases  there  is  a  constitutional  or 
hereditary  weakness  of  the  digestive  system,  which  is  aggravated  by 
an  exceptional  strain  or  overwork  of  the  nervous  system.  The  phe- 
nomena of  growth  and  development  of  the  different  organs  necessi- 
tates the  consumption  of  a  relatively  larger  quantity  of  good  food 


THE   CIRCULATORY   SYSTEM   AND   BLOOD. 


459 


than  is  needed  later  in  life  for  merely  maintaining  the  equilibrium 
of  the  tissues  and  restoring  the  balance  of  material  used  in  the 
production  of  energy.  Growth  implies  the  building  up  of  new  mate- 
rial and  a  renewal  of  the  old  as  well.  At  the  period  of  growth,  there- 
fore, there  are  always  unusual  demands  upon  the  nervous  system, 
and  overstrain  at  this  time  is  to  be  especially  guarded  against. 

Symptoms. — Among  the  many  symptoms  referable  to  the  nerv- 
ous system  which  occur  in  the  course  of  protracted  anaemia  are 
languor,  vertigo,  various  forms  of  neuralgia  and  megrim,  with  in- 
definite muscular  pains,  which  to  some  extent  are  produced  by  en- 
feebled circulation,  which  allows  waste  material  produced  by  muscular 
action  to  accumulate  in  the  tissues.  Depression  of  spirits  and  drow- 
siness are  also  observed,  and  palpitation  is  easily  excited.  The  poor 
circulation  may  result  in  the  production  of  fainting,  or  of  oedema  in. 
the  lower  extremities.  In  advanced  anaemia  it  is  found  that  not  only, 
is  the  normal  rate  of  tissue  metabolism  impaired,  but  there  may  be 
modifications  in  the  relative  consumption  of  certain  foods  by  the  tis- 
sues. A  large  excess  of  urea  is  commonly  observed,  which  indicates 
an  active  combustion  of  nitrogenous  substances.  The  view  is  widely 
held  that  owing  to  the  small  number  of  the  red  disks,  or  oxygen  car- 
riers, the  final  oxidation  of  fatty  matter  is  retarded,  and  it  is  for  this 
reason  that  anaemic  subjects  very  often  appear  plump  or  even  cor- 
pulent from  the  deposition  of  a  large  amount  of  fat  derived  from 
imcomplete  combustion  of  fats  and  starches,  whereas  their  muscles, 
from  the  increased  nitrogenous  waste,  are  reduced  in  size  and  are 
weak.  Van  Noorden,  Kraus,  Bohland,  and  others  dissent  from  this 
argument  and  believe  that  chlorotic  patients  feel  tired,  sleep  long, 
and  are  disinclined  to  expend  energy  in  muscular  exertion,  and  less 
energy  than  usual  goes  into  heat  production,  and  as  they  sometimes 
eat  abundantly  of  sugars  and  starches,  they  necessarily  store  up  fat, 

Rest,  Exercise,  and  Air.— In  many  cases  of  extreme  anaemia, 
found  especially  among  young  chlorotic  girls,  the  dietetic  treatment 
must  be  accompanied  by  careful  regulation  of  all  hygienic  conditions. 
Sufficient  rest  for  the  tissues,  and  especially  for  the  digestive  organs, 
must  be  secured.  These  patients,  who  appear  so  well  nourished,  may 
in  reality  be  quite  feeble,  and  it  is  a  great  mistake  to  compel  them  to 
rise  early  and  perform  tasks  and  indulge  in  exercises  of  the  same  char- 
acter and  degree  with  those  of  healthy  children.  For  many  patients 
it  is  well  to  insist  on  prolonged  and  continuous  rest  in  bed.  For 
others  it  will  suffice  to  restrict  the  activities  of  the  day  by  permitting 
the  patient  to  rise  shortly  before  noon,  and  to  insist  upon  rest  being 
taken  on  a  lounge  both  before  and  after  meals  in  order  to  secure 
more  perfect  digestion.  These  patients  must  be  cautioned  against 
allowing  themselves  to  become  unduly  fatigued.  They  are  often 
able,  under  the  influence  of  stimulants  and  excitement  of  various 


46q 


DIET   IN   DISEASE. 


sorts,  to  perform  f^ats  of  exercise  or  endurance  which  are  equal  to 
those  of  healthy  persons,  but  a  strong  reaction  is  certain  to  follow, 
and  a  steady  but  slow  progress  will  often  be  checked  for  several 
weeks  by  infringement  of  necessary  regulations.  In  such  cases,  how- 
ever, as  soon  as  decided  improvement  is  evident,  and  in  all  the  milder 
cases,  it  is  desirable  to  enforce  rules  for  gentle  exercise  in  the  open 
ait,  and  the  patient  should  be  outdoors  nearly  all  the  time  whenever 
the  weather  permits.  The  exercise  should  be  supervised  and  slowly 
increased  in  stout  subjects,  so  that  they  gradually  consume  their 
superfluous  fat.  If  the  climate  is  unfavourable  the  cure  will  be  much 
more  rapid  if  the  patient  can  be  moved  to  a  more  salubrious  locality. 
Fresh  air  is  more  important  than  exercise,  for  an  abundant  oxygen 
supply  increases  the  appetite  and  distinctly  favours  the  assimilation 
of  the  food. 

Dietetic  Treatment. — The  dietetic  treatment  of  anaemia  requires, 
in  the  first  place,  that  the  most  nutritious  food  should  be  supplied; 
secondly,  care  must  be  taken  to  insure  its  complete  digestion  and 
absorption.  In  all  cases  of  ahgemia  the  impoverished  and  watery 
condition  of  the  blood  reacts  unfavourably  upon  the  character  of  the 
digestive  secretions  and  diminishes  their  organic  elements.  The  se- 
cretions are  therefore  unable  to  digest  the  food  with  the  necessary 
vigour,  and  it  is  often  desirable  to  re-enforce  them  by  the  use  of  arti- 
ficially prepared  ferments  or  to  give  predigested  food,  making  use  of 
pancreatin,  in  the  preparation  of  animal  food,  and  diastase  or  malt 
extracts  for  the  predigestion  of  amylaceous  food  (see  pages  330,  331). 

At  the  commencement  of  treatment  rest  and  a  small  amount  of 
food  may  be  required,  but  with  improvement  of  the  digestive  organs 
the  quantity  of  food  must  be  rapidly  increased,  and  four  or  five  meals 
a  day  may  be  given.  At  first,  if  milk  is  well  borne  by  the  enfeebled 
digestive  system,  and  if  it  is  not  distasteful  to  the  patient,  it  should 
be  the  principal  food.  It  may  be  drunk  between  meals,  and  especially 
at  night  on  going  to  bed.  Some  of  these  patients  who  cannot  digest 
milk  with  facility  are  able  to  take  a  mixture  of  equal  parts  of  cream 
and  hot  water  with  ten  grains  of  bicarbonate  of  soda  and  a  teaspoon- 
ful  of  brandy  to  the  tumbler  (Yeo).  Eggs  in  all  forms  which  are  of 
fairly  easy  digestion  are  an  excellent  food  for  anaemic  subjects,  and 
rare  meat  should  be  given  in  considerable  quantities  two  or  three 
times  a  day.  Sandwiches  made  with  pounded  meat  or  beefsteak 
almost  raw,  which  is  placed  between  thin  slices  of  bread  and  butter, 
may  be  taken  with  meals,  or  as  a  light  lunch  in  the  middle  of  the 
morning  and  afternoon.  Inserting  a  crisp  lettuce  leaf  in  each  sand- 
wich makes  it  still  more  palatable  and  wholesome.  Patients  of  this 
class  often  object  very  strongly  to  eating  meat,  and  prefer  pastry 
and  sweets,  but  with  tact  and  persuasion  they  can  usually  be  induced 
to  take  it  in  some  form.     Meat  broths  and  consommes  may  be  thick- 


THE    CIRCULATORY  SYSTEM  AND   BLOOD.  461 

ened  with  scraped  meat,  or  raw  scraped  beef  may  be  added  to  choco- 
late or  Burgundy,  or  may  be  eaten  in  any  manner  agreeable  to  the 
patient.  In  this  way  large  quantities  of  meat  in  an  easily  digestible 
form  may  be  taken  without  tiring  of  it,  as  fat  anaemic  women  are 
very  apt  to  do. 

Young  chlorotic  girls  should  receive  at  least  five  or  six  ounces  of 
albumin /^r  diem. 

See  gives,  as  much  as  fourteen  ounces  of  raw  meat  daily  in  some 
cases  of  chlorosis,  and  finds  it  especially  serviceable  for  those  pa- 
tients whose  weak  stomachs  rebel  against  the  use  of  the  different 
preparations  of  iron. 

Anaemic  patients  often  feel  worse  during  the  first  half  of  the  day. 
They  then  complain  most  of  headache,  languor,  and  anorexia,  but 
they  should  be  encouraged  to  begin  the  day  early  with  nourishing 
albuminous  food  to  counteract  this  condition.  Van  Noorden's  sys- 
tem at  the  Berlin  Charite  is  excellent,  and  he  describes  it  as  follows 
(International  Medical  Mag3,zine,  May,  1894): 

"  I  recommend  chlorotic  girls  to  drink  slowly  half  a  litre  of  milk 
of  the  best  quality  while  they  are  yet  in  bed  in  the  morning.  They 
must  take  time,  and  occupy  at  least  a  quarter  of  an  hour  in  consum- 
ing this  quantity.  They  ought  to  rise  half  an  hour  later,  and  they 
should  be  rubbed  briefly  with  a  dry  rough  woollen  towel.  This  is  to 
be  followed  by  the  breakfast,  consisting  of  a  small  cup  of  tea,  one 
or  two  slices  of  buttered  toast,  and  plenty  of  meat.  I  consider  it 
extremely  desirable — the  physiological  reasons  for  this  are  easy  to 
defend — that  these  patients  should  take  in  at  breakfast,  before  the 
daily  work  commences,  as  much  albumin  as  possible.  Two  and  a 
half  hours  later  some  bread  and  butter  and  two  eggs  are  to  be  eaten, 
followed  immediately  afterwards  by  drinking  a  quarter  of  a  litre  of 
milk.  If  considered  advisable  for  special  reasons,  a  small  glass  of 
sherry  is  now  permissible." 

If  the  large  quantities  of  meat  recommended  are  not  perfectly 
digested  and  absorbed,  it  is  well  to  prescribe  some  preparation  of 
pepsin  with  dilute  hydrochloric  acid.  A  concentrated  meat  diet 
almost  always  produces  constipation  if  this  condition  does  not 
already  exist  as  a  result  of  the  anaemic  and  atonic  condition  of  the 
intestinal  wall,  or  the  giving  of  iron.  It  is  well  to  counteract  this 
tendency  by  the  use  of  draughts  of  hot  water  and  oi  purees  of  fresh 
vegetables,  whole-meal  bread,  oatmeal,  and  such  fruits  as  stewed 
prunes,  apples,  and  the  juice  of  oranges  and  grape  fruit  (see  Con- 
stipation. 

The  various  Italian  pastes,  such  as  macaroni,  vermicelli,  and 
polenta,  with  meat  gravies,  are  suggested  by  Yeo.  But  with  those 
patients  in  whom  there  is  a  tendency  to  overproduction  of  fat,  with- 
holding of  hydrocarbons  from  the  diet  is  highly  desirable. 


462 


DIET  IN  DISEASE. 


For  others  who,  besides  being  anaemic,  are  thin  and  poorly 
nourished,  it  is  well  to  add  some  simple  forms  of  starchy  food  and  a 
good  deal  of  fat  with  the  meals.     Van  Noorden  says  : 

"For  a  well-nourished,  moderately  fat,  chlorotic  girl,  weighing 
sixty  kilos,  I  would  consider  the  following  diet  as  eminently  suitable  : 

"  1 20  grammes  albumin  =        492  calories. 

60        "        fat  =        558 

270        "        carbohydrates     =     1,110        " 

Total 2,160        " 

(I.  e.,  36  calories  per  kilo  of  body  weight.)" 

The  eating  of  fats  is  to  be  encouraged  to  the  limit  of  toleration. 
Cream  and  large  quantities  of  butter  are  recommended  when  easily 
digested,  and  they  can  be  made  to  replace  cod-liver  oil  when  the 
patient  is  unable  to  take  this  form  of  fat.  Many  patients  can  digest 
broiled  fat  bacon  with  ease.  Two  or  three  eggs  beaten  with  boiling 
water  or  milk,  with  the  addition  of  sugar  and  spices  and  a  table- 
spoonful  of  brandy  or  sherry,  make  a  useful  form  of  eggnog,  which 
can  be  given  two  or  three  times  during  the  day  between  meals. 

The  use  of  glycerin  extracts  and  of  emulsions  of  bone  marrow 
has  been  advocated  within  the  past  year  for  anaemia.  The  method 
of  preparation  of  the  marrow  is  described  on  page  177. 

The  cases  thus  far  reported  by  Fraser,  Bigger,  Danforth,  J.  S. 
Billings,  Jr.,  Hamilton,  and  Walker  of  the  use  of  bone  marrow  in 
different  forms  of  anaemia  have  shown  considerable  benefit  from  this 
treatment.  The  condition  most  improved  is  chlorosis,  but  it  is 
claimed  that  some  cases  of  pernicious  anaemia  have  been  helped  by 
it.  The  number  and  quality  of  the  red  corpuscles  is  improved.  In 
Danforth's  case  the  percentage  of  haemoglobin  rose  from  35  to  80. 
Billings  (Johns  Hopkins  Hospital  Bulletin,  November,  1894,  page 
119)  denies  the  value  of  marrow  in  pernicious  anaemia,  and  thinks  its 
good  effect  in  the  cases  of  chlorosis  reported  by  him  is  attributable 
to  the  large  proportion  of  iron  which  the  marrow  contains. 

Most  anaemic  patients  have  no  appetite,  or  lose  it,  during  the 
early  part  of  the  day,  and  careful  attention  should  therefore  be 
given  to  making  all  their  food  as  agreeable  to  them  as  possible  in 
taste  and  manner  of  serving.  Meat  should  be  prepared  so  as  to  re- 
quire the  least  possible  effort  in  mastication,  and  much  more  food 
can  easily  be  consumed  in  a  fluid  and  semisolid  form. 

Condiments  are  serviceable,  for  they  render  simple  food  more 
agreeable  and  stimulate  the  enfeebled  gastric  secretion.  Moleschott 
insists  on  the  free  use  of  salt  by  chlorotic  patients  on  account  of  its 
supposed  favourable  action  in  restoring  the  blood  corpuscles  and 
plasma.     Vinegar,  pickles,  gravies,  and  sauces  should  be  avoided. 

Alcohol  is  not  indicated  for  all,  but  there  are  some  patients  who 


THE    URINARY   SYSTEM. 


463 


are  benefited  by  its  use,  and  the  best  form  of  alcoholic  tonic  for  an 
anaemic  patient  isa  good  rich  claret,  Burgundy,  or  Madeira.  Some 
of  the  milder  cases,  especially  women  in  whom  the  digestive  organs 
are  not  particularly  disturbed,  do  very  well  on  porter  or  stout,  or 
one  of  the  various  malt  preparations,  which  may  be  taken  with  the 
noonday  meal  or  at  bedtime  with  a  few  crackers  or  a  raw-beef  sand- 
wich. The  latter  is  a  prescription  very  serviceable  in  those  cases  in 
which  insomnia  is  a  harassing  symptom.  There  is  no  apparent  con- 
nection whatever  between  the  absorption  of  alcohol  and  the  forma- 
tion of  new  blood  cells,  although  there  is  a  popular  idea  to  the  effect 
that  red  wine  produces  red  blood.  Alcohol,  however,  often  does 
promote  the  accumulation  of  fat,  and  this  is  most  undesirable  in 
anaemic  subjects  who  already  possess  that  tendency. 

PERNICIOUS   ANEMIA. 

Hunter  (British  Medical  Journal,  July  5  and  12,  1890)  argues 
for  the  use  of  an  exclusively  farinaceous  diet  for  pernicious  anaemia, 
on  the  ground  that  in  health  a  proteid  diet  causes  more  extensive 
destruction  of  the  corpuscular  elements  of  the  blood  than  a  fari- 
naceous one,  and  in  this  disease,  on  account  of  putrefaction  in 
the  intestine,  the  blood  destruction  is  increased  by  nitrogenous  diet. 
This  theory  is  in  opposition  to  all  others,  and  the  most  satisfactory 
and  rational  treatment  consists  in  giving  predigested  milk,  eggs, 
beef  broth  and  juice,  etc.,  in  as  large  quantities  as  both  stomach 
and  rectum  will  absorb. 

There  is  defective  assimilation  of  proteid  foods,  and  hence  they 
should  be  thoroughly  predigested  (see  pages  331). 

DIET  IN   DISEASES  OF  THE  URINARY  SYSTEM. 

Modifications  in  the  Urine  caused  by  Food. 

The  quantity  as  well  as  the  composition  of  the  food  eaten  exercises 
an  important  influence  over  the  composition  of  the  urine.  Animal 
food  naturally  increases  the  nitrogenous  elements  of  the  urine,  urea, 
uric  acid,  and  urates,  and  vegetable  food  increases  the  carbonates 
and  earthy  salts. 

A  concentrated  diet  restricted  in  fluids  as  well  as  solids  reduces 
the  water  of  the  urine,  and 'makes  it  relatively  more  acid,  although 
the  absolute  quantity  of  acid  may  not  be  increased.  Conversely, 
watery  foods,  milk,  succulent  fruits  and  vegetables,  and  all  bever- 
ages increase  the  quantity  of  urinary  fluid  and  tend  thereby  to  lessen 
its  acidity  and  density. 

Cantani  dissents  from  the  common  view  that  the  organic  acids, 
such  as  fruit  acids,  form  carbonates  which  promote  alkalinity  of  the 
33 


464 


DIET   IN    DISEASE. 


urine,  and  says  that  this  is  true  of  small  quantities,  but  that  larger 
amounts  or  the  continued  administration  of  these  acids  makes  the 
urine  strongly  acid, 

A  diet  rich  in  fatty  food,  or  an  excess  of  cod-liver  oil,  may  some- 
times give  rise  to  fat  in  the  urine,  or  lipuria.  The  volatile  fatty  acids 
may  similarly  be  present.  The  presence  of  the  fat  makes  the  urine 
somewhat  turbid,  and  oil  globules  and  fat  crystals  may  sometimes 
be  seen  under  the  microscope. 

A  milk  diet  tends  to  make  the  urine  somewhat  alkaline,  and  it 
may  increase  the  quantity  of  indican. 

Foods  which  may  produce  oxaluria  are  described  under  Oxa- 
luria. 

The  peculiar  odour  which  asparagus  produces  in  the  urine  is  ex- 
plained on  page  154. 

Acute  Nephritis. 

Symptoms. — Acute  diffused  nephritis  is  an  inflammation  of  the 
kidneys,  which  is  principally  caused  by  exposure  to  cold  and  wet,  by 
certain  medicinal  poisons,  or  by  the  toxines  developed  in  the  course 
of  acute  infectious  fevers,  especially  the  exanthemata  and  diphtheria. 
It  is  unnecessary  to  discuss  its  varieties  here,  as  the  dietetic  treat- 
ment is  the  same  for  all. 

Among  the  important  symptoms  are  anaemia  and  a  scanty  secre- 
tion of  urine  containing  abundant  albumin  with  casts  and  blood. 
Anasarca  and  effusion  into  various  serous  cavities,  such  as  those  of 
the  pleura  and  peritonaeum,  may  occur.  The  arterial  tension  is 
increased.  The  patient  must  be  kept  in  bed  to  insure  a  uniform 
temperature  of  the  body,  and  facilitate  the  use  of  measures  to  pro- 
mote perspiration. 

Dietetic  Treatment. — The  dietetic  treatment  must  be  adapted 
to  prevent  overloading  the  digestive  organs,  which  are  easily  de- 
ranged, and  to  prevent  overworking  the  kidneys.  A  light  diet  is 
therefore  necessary.  The  patient  will  do  best  to  live  exclusively 
upon  milk  for  some  days,  until  the  functional  activity  of  the  kidneys 
is  restored.  The  importance  of  this  should  be  explained  to  him 
and  insisted  upon.  Between  four  and  seven  pints  are  to  be  taken 
daily,  diluted  with  Vichy  or  carbonic-acid  water.  If  the  bowels  are 
loose,  hme  water  may  be  added  instead  ;  or  if  constipated,  magnesia 
solution.  If  the  liver  seems  inactive,  skimmed  milk  or  buttermilk 
may  agree  better.  Milk  sometimes  causes  gastric  oppression.  If 
sipped  slowly,  or  taken  with  a  teaspoon,  this  may  be  overcome,  for 
it  is  then  diluted  with  the  saliva. 

If  milk  is  strenuously  objected  to  or  actually  disagrees  with  the 
patient,  other  simple  foods  may  be  allowed,  such  as  koumiss,  butter- 
milk, and  gruels  of  oatmeal,  groats,  rice,  barley  flour,  or  arrowroot. 


THE   URINARY   SYSTEM.  465 

These  forms  of  starchy  food  should  be  prepared  without  much  sugar, 
but  a  little  cream  may  be  added  or,  if  preferred,  the  juice  of  a  lemon, 
but  no  vegetables  are  permitted.  If  the  patient  is  feeble,  strong 
beef  tea  or  beef  or  chicken  broth  are  sometimes  to  be  recom- 
mended, but,  in  general,  so  long  as  the  symptoms  are  at  all  acute 
it  is  necessary  to  withhold  all  meat  preparations  from  the  diet. 
This  is  especially  true  in  the  case  of  young  children.  Animal  broths 
dissolve  substances  from  meat  which  easily  develop  into  toxines  and 
irritate  the  kidneys. 

When  the  kidneys  become  more  active  and  the  character  of  the 
urine  improves,  the  diet  may  be  increased  by  such  articles  as  bread 
and  butter,  plain  puddings,  lettuce,  or  water  cress  with  plain  French 
dressing,  stewed  apples,  grapes,  oranges,  etc.,  but  whenever  possible 
the  food  should  consist  largely  of  milk  for  a  long  period.  Later, 
eggs  and  even  meat  broths  may  be  allowed,  and  finally  a  little  white 
meat  of  poultry. 

Any  return  of  the  albuminuria  should  be  immediately  met  by  a 
reduction  in  the  diet  to  its  original  simplicity — chiefly  milk. 

A  patient  may  lose  thirty  or  forty  grains  of  albumin  in  twenty- 
four  hours  without  serious  harm,  but  if  three  hundred  to  four  hun- 
dred grains  are  lost  the  condition  is  in  itself  alarming,  for  he  is 
losing  from  one  fifth  to  one  fourth  of  his  total  albuminous  food 
through  leakage  of  the  kidneys — i.  e.,  he  is  passing  daily  in  the  urine 
one  twelfth  of  the  nutrient  matter  of  his  blood  (Granger  Stewart). 
A  pint  of  milk  supplies  about  an  ounce  of  albumin  and  casein,  thus 
replenishing  the  waste. 

The  lactose  of  milk  is  sometimes  given  separately  for  its  diuretic 
action,  S^e  gives  it  up  to  three  ounces  in  twenty-four  hours,  to  be 
drunk  in  two  quarts  of  water,  and  he  believes  it  acts  best  when  car- 
diac dropsy  is  also  present  and  the  quantity  of  albumin  is  not  large. 
I  have  found  it  difficult  to  push  its  use  to  such  a  degree  without 
causing  dyspepsia  and  a  decided-  dislike  for  it.  Milk  is  undoubt- 
edly a  good  mild  excitant  of  renal  activity,  but  this  is  due  to  its 
water  as  much  as  to  any  other  ingredient,  and  the  diuretic  effect  of 
lactose  is  much  overrated. 

Should  vomiting  occur  at  any  time,  the  diet  must  be  again  re- 
duced, or  it  may  be  advisable  to  give  the  stomach  complete  rest  for 
ten  or  twelve  hours.  To  increase  the  activity  of  the  skin  and  wash 
the  casts  and  debris  of  granular  matter  and  blood  corpuscles  from 
the  renal  tubules,  the  blood  volume  must  be  raised  by  the  ingestion 
of  abundant  fluid,  provided  the  tendency  to  dropsical  effusions  is 
not  great.  Water,  alkaline,  mineral,  or  effervescing  waters,  soda 
lemonade,  or  cream-of-tartar  lemonade  should  be  drunk  freely,  the 
latter  especially  if  there  is  constipation  (Dickinson).  Osier  rec- 
ommends the  following:  A  drachm  of  cream  of  tartar  in  a  pint  of 


466 


DIET   IN    DISEASE. 


boiling  water  with  the  addition  of  the  juice  of  half  a  lemon  and  a 
little  sugar.     To  be  drunk  cold. 

It  is  a  general  rule  to  exclude  all  foods  and  drinks  which  may  in 
any  way  irritate  the  kidneys,  and  the  following  are  especially  for- 
bidden :  Grills,  roasts,  sauces,  pastry,  spices,  very  acid  foods,  strong 
alcoholic  drinks,  tea  and  coffee.  Strong  wines,  sweet  wines,  and  all 
sorts  of  liquors  are  absolutely  prohibited.  If  alcohol  seems  neces- 
sary for  the  stimulation  of  the  heart,  a  little  weak  claret,  white  wine, 
or  diluted  whisky  and  some  effervescing  water  may  be  given. 

ACUTE   NEPHRITIS   IN   CHILDREN. 

When  the  disease  occurs  in  children,  as  often  happens  during  or 
after  acute  infectious  diseases,  such  as  scarlatina  and  diphtheria,  the 
diet  must  consist  wholly  of  milk.  During  the  most  acute  stage  of 
nephritis  the  milk  may  be  diluted  one  half  with  Vichy  or  water  for 
its  diuretic  influence.  It  should  be  given  in  moderation,  but  often 
— say  at  least  once  in  two  hours.  As  the  acute  symptoms  subside 
milk  is  to  be  ordered  in  full  strength. 

Gradually  other  articles  may  be  added,  such  as  crackers,  toast, 
porridge,  rice  pudding,  cornstarch,  junket,  and  blancmange.  Orange 
juice  may  be  taken  freely,  and  an  occasional  baked  apple  with 
cream  or  a  few  stewed  prunes  will  act  favourably  upon  the  bowels. 

It  is  best,  as  in  the  case  of  adults,  to  forbid  meat  broths,  and 
eggs  and  meat  in  any  form  must  be  withheld  for  three  or  four  weeks 
after  the  urine  has  regained  its  normal  composition.  Subsequently 
a  menu  may  be  composed  from  such  articles  as  a  chop,  the  breast 
of  a  chicken  or  partridge,  a  little  broiled  whitefish,  a  poached  egg, 
oysters,  custard,  a  baked  mealy  potato  with  fresh  butter,  stale 
bread,  wine  jelly,  and  fresh  ripe  fruits. 

Albuminuria. — Functional  Albuminuria. 

Pathological  Physiology. — ^Albuminuria  may  be  produced  by 
alterations  in  the  composition  of  the  blood  and  by  structural  or 
functional  changes  in  the  kidney  itself,  or  by  both.  The  albumin  is 
derived  from  the  blood  serum,  which  in  turn  comes  from  the  proteid 
material  of  the  food.  Under  ordinary  circumstances  proteid  mat- 
ter in  passing  through  the  body  undergoes  several  transformations 
which  affect  its  degree  of  solubility  and  its  ability  to  osmose  or  go 
through  animal  membranes  such  as  line  the  alimentary  canal,  the 
blood  vessels,  and  the  tubules  of  the  kidney.  Most  proteid  matter 
taken  into  the  body  as  food  is  not  readily  absorbed  until  converted 
into  some  form  of  peptone  or  albumose.  These  substances  diffuse 
very  easily,  and  their  presence  in  the  blood  would  render  them  liable 
to  constant  osmosis  from  the  vessels  into  the  lymph  spaces  or  tis- 
sues  almost   immediately    after    absorption,    but    in    their    transit 


THE   URINARY  SYSTEM.  467 

through  the  intestinal  villi  they  are  reconverted  into  serum  albumin, 
which  does  not  osmose  easily,  and  which  therefore  remains  in  the 
vascular  system.  A  certain  amount  of  albuminous  material,  how- 
ever, must  pass  by  osmosis  from  the  blood  vessels  into  the  lym- 
phatic channels,  and  thence  into  the  tissues  which  surround  them  or 
which  they  penetrate.  For  serum  albumin  to  pass  into  the  urine  it 
must  osmose  through  two  layers  of  cells — namely,  the  capillary  wall 
of  the  blood  vessel  and  the  epithelial  lining  of  the  tubules  of  the 
kidney.  Variations  in  the  density  of  these  walls,  and  probably  also 
alterations  in  the  functional  activiy  of  the  epithelial  cells  which 
compose  them,  will  modify  the  rate  of  osmosis  so  that  it  may  be 
completely  checked,  or  it  may  be  allowed  to  take  place  unhindered. 
The  conditions  of  osmosis  also  depend  upon  the  relative  density  of 
the  fluids  on  either  side  of  the  membrane,  hence  alterations  in  the 
composition  of  the  blood  plasma  may  allow  of  the  osmosis  of  serum 
albumin  into  the  tubules  of  the  kidney.  It  is  important  to  observe 
that  the  presence  of  serum  albumin  in  the  urine  in  excess  not  only 
indicates  a  functional  or  structural  weakness  in  the  kidneys  them- 
selves, or  in  the  composition  of  the  blood,  but  it  represents  actual 
loss  of  substance  from  the  body — i.  e.,  of  material  which  is  not  yet 
converted  into  waste  matter,  but  which  is  capable  of  furnishing  nu- 
trition to  the  tissues — in  other  words,  there  is  a  leak  of  nutrient 
matter  from  the  kidneys. 

From  the  foregoing  statements  it  might  seem  feasible  to  disre- 
gard the  leakage  and  increase  the  amount  of  nitrogenous  food 
sufficiently  to  counterbalance  the  loss  sustained.  The  same  plan 
might  theoretically  be  thought  to  be  of  benefit  in  cases  of  diabetes, 
where  it  would  seem  quite  possible  to  counterbalance  the  loss  of 
saccharine  material  from  the  kidneys  by  ingestion  of  much  larger 
quantities  of  starches  and  sugars;  but  this  is  a  fallacious  compar- 
ison, for  excess  of  sugar  is  really  a  foreign  body  in  the  blood,  while 
albumin  is  not  (Granger  Stewart).  Clinically,  however,  it  has  been 
found  that  when  either  of  these  conditions  of  loss  of  substance 
from  the  blood  exists  in  the  kidneys  it  is  better  to  withhold  as 
much  as  possible  the  particular  variety  of  food  which  is  leaking 
through  them  and  reduce  the  work  of  these  organs,  hoping  by  rest, 
combined  with  other  appropriate  means  of  relief,  to  cure  the  faulty 
condition. 

Functional  Albuminuria. — Temporary  functional  albuminuria 
is  now  recognised  as  occurring  in  many  individuals  without  the 
significance  of  any  structural  or  organic  lesion  of  the  kidney.  This 
subject  has  been  exhaustively  investigated  by  the  medical  ex- 
aminers of  life-insurance  companies,  for  it  is  of  great  importance 
not  only  to  discover  the  presence  of  albuminuria  early,  but  to  as- 
sign the  proper  significance,  to  its  presence.     It  is  not  many  years 


468 


DIET   IN   DISEASE. 


since  the  detection  of  albumin  in  the  urine  was  regarded  as  an  in- 
fallible indication  of  some  form  of  renal  disease,  but  the  fact  is 
now  established  that  errors  in  diet  and  faulty  assimilation  produced 
by  mental  and  nervous  strain,  overwork,  and  worry,  and  more  paF- 
ticularly  by  the  exhaustion  of  very  rapid  growth  of  the  body  in  the 
later  years  of  childhood  and  early  youth,  may  occasion  albuminuria. 

A  solution  of  meat  albumin  experimentally  transfused  into  the 
venous  circulation  of  a  dog,  injected  either  subcutaneously  or  into 
the  rectum,  reappears  unaltered  in  the  urine,  but  serum  albumin 
similarly  injected  is  retained  by  the  blood  and  does  not  cause 
albuminuria,  although  the  percentage  of  albumin  in  the  blood 
plasma  has  been  considerably  raised  above  the  normal.  Moreover, 
if  a  man  in  health  eats  eight  or  ten  raw  eggs  in  the  course  of  five  or 
six  hours,  unaltered  egg  albumen  may  appear  in  the  urine.  Albumi- 
nuria thus  produced  is  purely  temporary,  and  is  directly  dependent 
on  the  nature  of  the  food.  So  much  of  this  proteid  has  been  eaten 
that  a  portion  of  it  is  absorbed  directly  into  the  blood  without  the 
formation  of  intermediate  products  of  digestion.  Similarly  this 
albumin  will  osmose  through  the  kidney.  But  if  the  digestive 
activity  in  the  stomach  is  very  great,  a  large  number  of  raw  eggs 
may  be  eaten,  and  as  many  as  nineteen  have  been  taken  in  thirty-six 
hours  (Dolradin)  without  the  appearance  of  albuminuria.  It  is  no 
doubt  true  in  such  an  instance,  as  suggested  by  Yeo,  that  the  vigour 
of  the  digestion  converts  egg  albumen  into  peptones,  which  finally 
form  serum  albumin,  whereas  with  a  slower  digestion  more  of  the 
egg  albumen  is  absorbed  unaltered. 

According  to  the  experiments  of  Stokvis,  coagulated  egg  albu- 
men cannot  be  made  to  reappear  in  the  urine  of  healthy  animals,  but 
raw  egg  albumen  can. 

Oertel  (Therapeutics  of  Circulatory  Derangements,  in  von  Ziem- 
ssen's  Handbook  of  General  Therapeutics),  as  a  result  of  numerous 
experiments  upon  man  and  animals  in  opposition  to  the  above  view, 
declares  that  "  egg  albumen,  given  in  whatever  quantity,  is  not  nor- 
mally excreted  as  such  by  the  kidneys,  and  does  not  cause  albumi- 
nuria." The  albumin  absorbed  is  all  destroyed  in  the  blood  or  tissues 
and  excreted  as  urea  from  the  kidneys.  He  further  says  that  "a 
great  increase  of  albumin  supplied  to  the  blood  causes  no  increased 
excretion  of  albumin  by  the  kidneys,  and,  in  particular,  that  egg  al- 
bumen gives  rise  to  no  irritation  of  the  renal  vessels  and  no  albu- 
minuria (nor  does  it  increase  an  existing  albuminuria)." 

This  statement,  if  corroborated  by  further  observation,  would 
considerably  alter  the  prevailing  notions  in  regard  to  the  advisa- 
bility of  giving  eggs  to  patients  with  chronic  Bright's  disease. 

Of  all  the  varieties  of  albuminuria,  those  which  are  most  amen- 
able to  dietetic  treatment  are  the  functional  form  and  that  which 


THE   URINARY   SYSTEM.  469 

accompanies  chronic  Bright's  disease.  The  functional  albuminuria 
which  is  produced  by  eating  an  excess  of  proteid  material  or  by  mus- 
cular fatigue,  which  results  in  the  accumulation  of  large  quantities 
of  nitrogenous  waste  matter  and  interference  with  normal  oxidation 
processes,  is  usually  curable  by  ascertaining  and  removing  the 
cause. 

It  seems  to  be  almost  impossible  to  produce  functional  albumi- 
nuria in  the  lower  animals,  such  as  dogs,  by  overfeeding  them  with  a 
very  large  excess  of  albuminous  food.  Voit  caused  a  dog  to  absorb 
within  twenty-four  hours  six  times  the  amount  of  albumin  contained 
in  the  blood  plasma  without  exciting  albuminuria. 

In  the  instance  given  above  of  albuminuria  caused  by  eating 
large  numbers  of  eggs,  it  was  emphasised  that  the  proteid  in  the 
urine  is  egg  albumen  and  not  serum  albumin.  It  is  stated,  however, 
that  occasionally  serum  albuminuria  may  be  produced  in  man  by 
eating  large  quantities  of  meat.  If  true,  this  is  certainly  very  un- 
usual, and  this  form  of  albuminuria  is  by  no  means  as  readily  in- 
duced as  the  glycosuria  caused  by  an  excess  of  starches  in  the  food. 
But  if  albuminuria  already  exists,  certain  forms  of  nitrogenous  food 
will  greatly  increase  the  amount  eliminated  by  the  kidneys. 

It  is  probable  that  some  persons  inherit  a  special  weakness  of  the 
kidney  structure  or  an  abnormal  irritability  of  the  renal  cells  which 
favours  the  occurrence  of  albuminuria  from  slight  provocation. 
Granger  Stewart  (Lectures  on  Important  Symptoms  of  Albumi- 
nuria, page  145)  states  that  he  has  observed  in  certain  persons  that 
cheese,  pastry,  and  eggs  are  substances  capable  of  producing  tem- 
porary albuminuria.  In  one  case  this  symptom  was  accompanied  by 
oedema  of  the  eyelids. 

In  regard  to  the  production  of  functional  albuminuria  from  diet- 
etic errors  Yeo  argues,  and  I  think  correctly,  as  follows :  "  May  not 
the  true  explanation  be  that  the  ingestion  of  so  large  an  excess  of 
albuminous  material  may  throw  upon  the  kidneys  such  an  excess  of 
nitrogenous  waste  (to  be  secreted)  that  a  temporary  functional  hy- 
peremia of  the  kidneys  is  excited,  and  that  this  leads  to  a  slight 
escape  of  albumin  from  the  blood  ?  It  appears  to  us  that  this  is  a 
sound  physiological  explanation  of  what  is  observed  to  occur,  and 
accounts  for  its  occurrence  in  fever  or  disordered  constitution,  and 
not  in  the  perfectly  sound  and  vigorous." 

Albuminuria  also  results  from  passive  hyperaemia  of  the  vessels 
of  the  kidney,  as  well  as  from  active  congestion  and  inflammation. 

In  functional  albuminuria,  when  traces  of  serum  albumin  appear 
from  time  to  time  in  the  urine,  it  is  found  that  the  amount  is  pro- 
portionately increased  by  any  special  fatigue  or  exhaustion.  It  is 
possible,  although  it  is  by  no  means  proved,  that  nerve  currents 
supplying  the  epithelial  cells  of  the  renal  tubules  or  the  walls  of  the 


^70  ^lET   IN   DISEASE. 

renal  capillaries  may  cause  a  functional  alteration  in  the  activity  of. 
these  cells,  which  compels  them  to  exercise  a  selective  action  upon 
the  albumin  of  the  blood  serum,  and  favours  its  osmosis.  The 
theory  is  advanced  by  Mills,  of  Montreal,  that  the  epithelium  of  the 
capillaries  possesses  some  at  least  of  the  functions  of  glandular 
epithelium,  and  that  it  is  capable  of  controlling  and  varying  the 
quality  as  well  as  the  quantity  of  such  substances  as  may  pass 
through  the  minute  capillary  walls. 

Albuminuria  is  very  common  as  a  result  of  elimination  of  irritant 
poisons  from  the  kidneys,  and  it  is  believed  that  the  albuminuria 
usually  present  in  diphtheria  and  the  exanthemata  is  produced  by 
the  irritant  effect  upon  the  kidneys  of  toxines  developed  in  these 
diseases  which  are  being  eliminated  in  the  urine. 

Dietetic  Treatment. — The  frequent  return  of  functional  albu- 
minuria should  be  regarded  as  an,  indication  of  special  weakness  of 
the  kidneys  in  the  same  way  that  frequent  glycosuria  invites  suspi-. 
cion  of  the  strength  of  the  digestive  power  of  the  liver,  and  it  de- 
mands a  careful  regulation  in  the  diet.  Meat  should  be  reduced  in 
quantity,  or  temporarily  forbidden,  as  well  as  all  forms  of  alcoholic 
drinks  or  other  substances  liable  to  produce  renal  irritation,  and  the 
diet  should  consist  chiefly  of  fruits,  vegetables,  and  milk.  Careful 
attention  must  be  paid  to  increasing  the  activity  of  the  bowels. 
When  functional  albuminuria  is  observed  in  children  and  adoles- 
cents, it  is  not  necessary,  nor  is  it  advisible  in  ordinary  cases,  to 
wholly  exclude  nitrogenous  food,  but  it  should  be  restricted,  espe- 
cially in  regard  to  eating  butcher's  meat  and  eggs,  and  the  evening 
meal  should  be  made  very  simple,  consisting  of  food  such  as  bread,, 
crackers,  rice  or  porridge,  and  milk. 

Chronic  Bright's  Disease. 

Causation. — Chronic  interstitial  nephritis  may  be  of  primary 
origin,  or  it  may  occur  as  a  result  of  arterio-fibrosis  and  other  con- 
ditions. It  is  usually  a  very  slow  process,  and  is  believed  to  be  pro- 
voked by  chronic  alcoholism  and  errors  in  diet,  such  as  a  too  great 
proportion  of  meat  in  the  food,  which  results  in  the  overproduction 
of  uric  acid  or  lithaemia  from  functional  derangement  of  the  liver. 

Urine  of  a  low  specific  gravity  is  passed  in  greater  amount  than 
normal,  and  thirst  is  increased.  The  arterial  walls  are  thickened  and 
their  tension  is  high. 

That  an  exclusive  meat  diet  is  not  alone  the  cause  of  chronfc 
Bright's  disease  is  proved  by  the  fact  that  Eskimos  and  other  races, 
who  subsist  altogether  upon  it,  are  not  especially  liable  to  the  dis- 
ease, although  in  the  long  sunless  winter  they  live  under  very  bad 
hygienic  conditions  (see  the  relation  of  proteid  food  to  albumi- 
nuria, page  468).     It  is  nevertheless  a  fact  that  the  disease  is  very 


THE   URINARY   SYSTEM. 


471 


prevalent  in  this  country  among  men  past  forty  years  of  age  who 
for  years  have  been  overworked  with  business  cares,  and  who  have 
neglected  to  take  sufficient  exercise  and  care  in  eating.  In  the  early 
stages  of  the  disease  much  may  be  accomplished  by  dietetic  treat- 
ment. Osier  says  that  "  care  in  food  and  drink  is  probably  the  most 
important  element  in  the  treatment  of  these  early  cases." 

Whatever  views  may  be  entertained  in  regard  to  the  causation  of 
albuminuria,  it  is  agreed  by  all  that  cooked  meats,  eggs,  and  highly 
seasoned  food  in  general  are  injurious  in  all  cases  of  existing  albu- 
minuria. One  should  be  cautioned  against  regarding  the  amount  of 
albumin  present  in  the  urine  from  time  to  time  in  the  course  of 
chronic  albuminuria  as  an  exact  indication  of  the  extent  of  the  renal 
disease.  The  fluctuations  observed  are  often  due  to  diet  merely,  and 
the  albumin  may  occasionally  be  considerably  reduced  in  quantity, 
or  actually  absent  temporarily  from  the  urine,  although  the  lesion  of 
the  kidneys  is  making  uninterrupted  progress.  The  volume  of  al- 
bumin in  the  urine  must  not,  therefore,  be  estimated  alone  as  an 
indication  for  dietetic  treatment ;  it  is  merely  one  of  many  symp- 
toms incident  to  the  course  of  chronic  Bright's  disease  which  are 
benefited  by  a  strict  regimen. 

Extensive  disease  of  the  excretory  surface  of  the  kidneys  always 
interferes  with  the  normal  elimination  of  nitrogenous  waste  matter 
which  accumulates  in  the  system  until  it  finally  produces  toxic  or 
uraemic  symptoms  of  a  most  serious  character.  If  the  alimentary 
canal  is  overloaded  with  food  above  the  actual  requirements  of  nu- 
trition, or  beyond  the  capabilities  of  the  system  for  oxidising  food 
products,  toxic  symptoms  are  sure  to  follow.  For  these  reasons  the 
diet  in  chronic  Bright's  disease  must  be  definitely  regulated,  and  a 
mean  must  be  maintained  between  overburdening  the  digestive  ap- 
paratus and  withholding  food  which  is  needed  to  support  the  bodily 
strength.  This  applies  especially  to  the  waste  of  nitrogenous  food, 
which  passes  off  through  the  kidneys,  whereas  the  waste  of  farina- 
ceous food  is  eliminated  largely  from  the  lungs  and  skin  in  the  form 
of  water  and  carbonic  acid. 

Milk  Diet. — In  many  cases  of  chronic  Bright's  disease  the  effect 
of  feeding  the  patient  for  six  weeks,  or  even  two  or  three  months, 
upon  an  exclusive  milk  diet  is  remarkably  gratifying.  The  quantity 
of  urine,  urea,  and  extractives  increases,  while  the  albumin  dimin- 
ishes, iand  oedema  and  general  anasarca  disappear.  The  patient's 
strength  and  general  condition  improve,  the  pulse  is  strengthened, 
and  if  dyspnoea  pre-existed  it  subsides. 

The  quantity  of  milk  to  be  prescribed  for  an  exclusive  milk  diet 
in  Bright's  disease  must  depend  on  the  age  and  size  of  the  patient, 
as  well  as  upon  his  ability  to  take  exercise  and  use  up  force  in  mus- 
cular energy.     If  the  patient  is  invalided  so  as  to  be  confined  to  his 


.-2  I^IET   IN   DISEASE. 

room  or  the  house,  from  five  to  seven  pints  of  milk  daily  are  quite 
sufficient.  Seven  pints  of  milk  contain  216  grammes  of  albumin  and 
casein,  172  grammes  of  butter,  and  161  grammes  of  lactose;  whereas, 
according  to  Pettenkofer  and  Voit,  a  healthy  adult  requires  137 
grammes  of  dry  albumin,  117  grammes  of  fat,  and  352  grammes  of 
carbohydrates  (see  page  264).  The  milk  diet  is  therefore  deficient  in 
carbohydrates,  but  the  latter  are  estimated  in  Volt's  table  for  a  person 
taking  active  exercise,  and  requiring  the  development  of  more  muscu- 
lar energy  and  heat  than  the  invalid.  If  the  patient  loses  weight  on 
a  milk  diet,  although  it  otherwise  agrees  with  him,  it  may  be  well  to 
add  farinaceous  food  in  the  shape  of  rice  or  bread.  Many  patients 
will  live  contentedly  with  no  other  food  than  a  bowl  of  bread  and 
milk  four  or  five  times  a  day.  In  some  cases  it  is  inadvisable  to 
commence  the  milk  diet  immediately,  and  a  good  result  can  be  best 
attained  by  cutting  off  one  article  of  solid  food  after  another  and 
replacing  the  loss  by  an  additional  tumbler  of  milk.  Where  it  is  ex- 
pected to  employ  a  milk  diet  for  many  months,  as  in  an  advanced 
case  of  Bright's  disease,  it  is  usually  found  that  the  milk  is  better 
borne  if  taken  fresh  at  a  natural  temperature  and  without  flavouring 
of  any  kind.  Although  the  treatment  may  seem  severe  at  first,  if 
the  patient  understands  the  gravity  of  the  situation  he  is  usually 
willing  to  accept  it,  and  after  a  few  days  seldom  complains  of  the 
monotony  of  this  most  restricted  form  of  feeding.  In  the  worst 
cases  it  is  desirable  to  give  the  milk  at  brief  intervals,  in  quantities 
of  six  ounces,  once  an  hour  during  the  daytime,  with  an  extra  tum- 
blerful at  night,  and  on  awakening  in  the  morning.  Ordinarily, 
however,  it  is  tiresome  to  have  to  drink  milk  so  often,  and  the  quan- 
tity may  be  so  regulated  as  to  give  the  requisite  amount  once  every 
three  hours.  The  quantity  of  milk  necessary  to  support  life  for  any 
length  of  time  and  maintain  good  nutrition,  especially  if  the  patient 
is  exercising  at  all,  is  considerable,  and  he  must*  take  from  fourteen 
to  eighteen,  or  even  twenty-two  six-ounce  tumblerfuls  of  milk  in  the 
twenty-four  hours.  It  is  usually  impossible  to  commence  at  this  rate 
without  producing  gastric  disturbance  from  souring  of  the  milk  in 
the  stomach,  and  possibly  diarrhoea.  The  latter  symptom  is  an  al- 
most certain  indication  that  the  milk  is  being  imperfectly  digested, 
and  a  temporary  reduction  in  its  quantity  is  advised. 

It  is  very  important  to  thoroughly  cleanse  the  mouth  after  drink- 
ing the  milk,  in  order  to  avoid  coating  of  the  tongue  and  the  dis- 
agreeable taste  which  destroys  the  appetite  and  interferes  with  the 
efficacy  of  the  treatment.  For  a  full  discussion  of  this  subject  the 
reader  is  referred  to  the  article  on  milk  diet  in  typhoid  fever  (page 
398).  Obstinate  constipation,  which  almost  invariably  results  from 
a  long-continued  milk  diet,  must  be  met  by  medicinal  treatment,  or 
the  use  of  glycerin  suppositories  or  enemata.     As  a  rule,  the  milder 


THE   URINARY   SYSTEM. 


473 


laxatives  are  the  only  remedies  necessary ;  a  glass  of  citrate-of-mag- 
nesia  solution,  a  half  tumblerful  of  bitter  water  taken  on  rising  in 
the  morning,  a  drachm  of  the  compound-licorice  powder,  or  a  two- 
grain  pill  of  extract  of  cascara  sagrada  at  night,  will  prove  sufficient. 
There  is,  however,  no  objection  in  most  cases  to  allowing  the  use  of 
a  few  stewed  prunes  or  the  soft  part  of  two  or  three  baked. apples. 

It  will  be  observed  that  whereas  the  normal  average  quantity  of 
urine  for  an  adult  male  is  fifty-two  ounces  for  the  twenty-four  hours, 
the  milk  diet  under  discussion  requires  the  ingestion  of  upward 
of  one  hundred  ounces  of  fluid.  This  necessitates  greatly  increased 
activity  of  the  kidneys,  but  the  polyuria  usually  results  in  the  re- 
moval of  the  anasarca  which  frequently  exists.  The  body  weight 
may  remain  normal,  or  even  be  slightly  increased  on  this  treatment. 
It  is  not  infrequently  diminished,  however,  but  much  depends  upon 
the  condition  of  the  patient  at  the  time  when  the  milk  diet  was  inau- 
gurated. The  abundant  urine  is  of  a  pale-yellowish  hue,  which  is 
somewhat  typical  of  the  milk  diet.  The  specific  gravity  is  low,  and 
the  reaction  may  be  neutral  or  faintly  acid  on  account  of  the  great 
dilution  of  the  fluid.  The  albumin,  which  at  first  may  be  present  in 
considerable  bulk — sufficient  when  coagulated  to  almost  solidify  the 
contents  of  the  test  tube — gradually  diminishes,  and  the  urea  and 
salts  increase.  In  mild  cases  this  milk  diet  should  be  continued 
from  four  to  eight  weeks,  after  which  a  slight  variation  may  be  al- 
lowed in  the  shape  of  farinaceous  food,  fresh  vegetables,  and  fruit, 
such  as  oranges  and  lemons.  In  other  cases  it  may  be  necessary  to 
prolong  the  treatment  for  half  a  year  or  more,  because  it  will  be 
found  that  any  attempt  to  materially  alter  the  diet  is  followed  by  an 
increase  in  the  albumin  and  dropsy,  with  return  of  other  symptoms. 
In  such  patients  the  lesion  of  the  kidney  is  far  advanced  and  in- 
curable, and  the  most  that  can  be  hoped  for  from  any  treatment  is 
an  amelioration  of  the  worst  symptoms,  and  it  is  found  that  in  many 
cases  this  can  be  best  secured  by  milk  diet.  For  the  class  of  cases 
in  which  this  treatment  is  found  for  any  reason  to  be  impracticable, 
either  from  the  persistent  refusal  of  the  patient  to  take  milk  or  from 
any  other  cause,  before  giving  up  its  use  efforts  should  be  made  to 
modify  its  preparation  in  various  ways,  tempting  the  patient  with 
different  flavours  and  with  light  farinaceous  foods,  of  which  milk 
forms  an  important  basis,  such  as  bread  and  rice  puddings.  A  good 
deal  of  milk  may  be  taken  in  very  weak  coffee  or  tea,  or  in  the 
form  of  soups  and  purees  made  with  celery  or  potatoes,  or  gruels 
may  be  given,  or  milk  thickened  with  tapioca,  vermicelli,  sago,  or 
rice,  and  flavoured  with  a  little  lemon  or  orange  peel,  cloves,  or  all- 
spice. It  is  not  desirable  to  use  much  high  seasoning  for  fear  of 
irritating  the  diseased  kidneys. 

As  the  patient  improves,  the  milk  diet  may  be  given  up,  but*  it 


._,  DIET   IN    DISEASE-.. 

474 

should  never  be  too  suddenly  abandoned.  A  sudden  restriction  of 
fluids  in  chronic  nephritis  is  always  injurious.  In  adopting  any  other 
diet  it  is  a  good  rule  never  to  let  the  nitrogenous  food  bear  a  greater 
proportion  to  the  non-nitrogenous  than  one  to  four.  The  former 
increases  the  proportion  of  urea  in  the  urine;  the  latter  reduces  it, 
A  purely  vegetable  diet  has  often  been  tried  for  albuminuriacs,  but 
it  causes  too  pronounced  ansemia  if  its  use  is  persisted  in,  and  a 
minimum  of  animal  food  must  therefore  be  prescribed.  Granger 
Stewart  says,  in  speaking  of  the  very  chronic  albuminuria  of  Bright's 
disease,  "In  the  more  advanced  stages  the  diet  should  be  as  nutri- 
tious as  possible,  and  then  certainly  fresh  meat  is  by  no  means 
injurious."  Vegetarianism  should  never  be  persisted  in  if  the 
patient  continues  to  lose  weight  and  strength. 

When,  after  a  milk  diet,  the  change  is  to  be  made  to  a  more 
liberal  menu,  the  hours  of  taking  the  milk  may  be  reduced  in  fre- 
quency, and  some  of  the  milk  may  be  replaced  by  boiled  fish, 
chicken,  or  game,  and  fresh  green  vegetables,  cream,  butter,  and 
bacon.  The  urine  should  still  be  periodically  examined,  and  if  it  is- 
found  that  the  eating  of  meat  is  followed  by  an  increase  in  the  al- 
buminuria the  patient  must  return  to  the  milk  diet. 

It  not  rarely  happens  that  strict  adherence  to  a  milk  diet  for- 
several  months  produces  more  lasting  improvement  in  the  action  of 
the  kidneys,  so  that  a  diet  to  which  steak,  roast  beef,  chops,  and 
eggs  are  admitted  may  not  only  be  well  borne,  but  may  increase  the 
strength  of  the  patient.  This  is  a  matter  which  obviously  cannot  be 
regulated  by  fixed  rules.  If  the  general  principles  of  the  treatment' 
are  understood,  it  is  within  the  province  of  any  intelligent  physician 
to  apply  them  to  individuals.  In  cases  in  which  it  is  found  after 
trying  all  methods  that  milk  cannot  be  assimilated  in  any  form,  the 
patient  must  live  upon  a  carbohydrate  diet,  consisting  of  fresh  vege- 
tables and  fruits,  with  butter,  cream,  and  olive  oil.  Dujardin-Beau- 
metz  allows  pork  and  ham  to  be  eaten  by  those  who  refuse  to  relin- 
quish meat  entirely.     Cheese  is  to  be  avoided. 

Senator  believes  that  whenever  serious  albuminuria  is  present 
egg  albumen  and  meat  should  be  withheld,  although  a  little  fish  or 
flesh  poor  in  albumin,  like  that  of  chicken  or  veal,  may  be  given  if 
necessary,  but  he  prefers  to  prescribe  only  vegetables,  salads,  and 
fruits,  or  ati  exclusive  milk  diet  of  two  litres /^r  diem. 

Semmola  recommends  the  use  of  the  following  drink,  which 
may  be  mixed  with  milk,  and  which  possesses  a  decided  diuretic 
action  : 

Sodium  iodide ic  grains. 

Sodium  phosphate 30      " 

Sodium  chloride , go      " 

Drinking  water 36  ounces. 


THE    URINARY   SYSTEM. 


475 


In  general,  the  patient  had  better  leave  alcohol  alone,  especially 
in  the  form  of  malt  liquors.  If  habituated  to  its  use,  a  feeling  of 
dulness  and  drowsiness  after  a  glass  of  wine  is  a  strong  reason  for 
giving  it  up.  An.  occasional  "spree"  may  do  the  patient  less  harm 
than  continued  drinking  in  smaller  quantity.  For  a  non-alcoholic 
subject,  if  weak  and  anaemic,  as  he  improves,  a  little  light  wine  or 
claret  diluted  with  Seltzer  water  or  Apollinaris  may  be  ordered  as  a 
beverage.     Tea,  coffee,  and  cocoa  are  permissible. 

The  effect  of  dietetic  treatment  will  be  much  enhanced  by  secur- 
ing systematic  outdoor  exercise  and  freedom  from  worry  and  anxiety, 
and  particular  attention  must  be  paid  to  keeping  the  bowels  open^ 
for  which  laxative  fruits  may  be  taken  freely.  The  patient  must  be 
cautioned  against  overeating,  and  all  food  must  be  thoroughly 
masticated. 

PYELITIS. 

Most  cases  require  abundant  fluid,  such  as  alkaline  mineral 
waters,  for  the  purpose  of  washing  out  the  pelvis  of  the  kidney,  and 
if  there  is  much  irritation  or  painful  micturition,  it- is  well  for  the 
patient  to  be  put  on  an  exclusive  milk  diet  for. a  month  or  six 
weeks  after  the  manner  described  above  for  treatment  of  nephritis 
in  the  preceding  section. 

Many  patients  are  benefited  by  attending  such  baths  as  Carlsbad, 

Vichy,  or  Neuenahr. 

OXALURIA. 

The  condition  of  oxaluria  may  be  unsuspected  by  the  patient,  or 
it  may  attract  his  attention  by  a  sensation  of  burning  in  the  urethra^ 
desire  for  frequent  micturition,  headache,  "nervousness,"  etc.    . 

Causation. — The  occasional  presence  of  a  trace  of  calcium  oxa-r 
late  in  the  urine  need  not  be  considered  as  abnormal,  but  the  con- 
tinued presence  of  excess  of  oxalate-of-lime  crystals  in  the  urine  is 
mainly  caused  by  eating  certain  kinds  of  food  and  by  dyspepsia  and 
perverted  nutrition,  involving  incomplete  oxidation  in  the  system  of 
starchy,  saccharine,  and  fatty  foods. 

Ellis  says  that  "  oxalic  acid  is  very  readily  prepared  in  the 
chemical  laboratory  by  the  action  of  reagents  upon  sugar,  .starch, 
and  cellulose.  This  fact  would  seem  to  render  probable  the  possi- 
bility of  its  formation  from  the  imperfect  oxidation  of  these  sub- 
stances in  the  body,"  especially  from  bacterial  fermentation  in  the 
alimentary  canal. 

FlOgge  has  shown  that  bacteria  can  form  this  acid,  and  its  crys- 
tals occur  in  the  intestine  and  are  often  found  in  the  faeces.  Oxa- 
luria is  common  in  connection  with  dyspepsia,  and  it  is  not  altogether 
improbable  that  some  of  it  may  be  derived  from  imperfect  digestion 
of  food  in  the  intestine,  and  be  absorbed  into  the  blood  just  as 
ptomaines  are. 


476 


DIET   IN   DISEASE. 


Cantani  finds  that  oxaluria  is  frequently  present  among  those 
who  indulge  too  freely  in  saccharine  and  amylaceous  foods.  Beneke 
holds  quite  an  opposite  theory,  and  attributes  the  condition  to  im- 
perfect metabolism  of  proteid  foods.  Even  fasting  animals  may 
still  show  traces  of  calcic  oxalate  in  their  urine,  and  both  in- 
creased and  diminished  oxidation  have  .been  held  accountable  for 
oxaluria. 

Vegetables  and  fruits  which  may  cause  it  when  eaten  in  excess 
are  rhubarb,  tomatoes,  turnips,  onions,  sorrel,  apples,  pears.  Raw 
fruits  and  vegetables  which  contain  citric,  malic,  and  other  organic 
acids  seem  to  bear  close  relation  to  the  formation  of  oxalic  acid. 
The  latter  is  not  necessarily  ingested  with  the  food,  but  is  produced 
in  the  body  from  a  variety  of  substances. 

Dietetic  Treatment. — The  diet  should  consist  of  animal  food — 
fish,  poultry,  game,  and  meat — with  stale  bread  or  toast  with  a 
minimum  of  butter.  Tea,  coffee,  carbonic-acid  water,  and  alcohol 
should  be  temporarily  forbidden.  Hot  water  (three  quarters  of  a 
pint)  should  be  sipped  half  an  hour  before  each  meal,  and  before 
breakfast  a  drachm  or  more  of  Carlsbad  salts  may  be  taken  in  con- 
stipated cases.  Dilute  mineral  acids,  hydrochloric  or  nitro-hydro- 
chloric,  are  beneficial  ordered  immediately  after  meals  in  doses  of 
fifteen  or  twenty  minims  in  water. 

CALCULI,   RENAL   AND   VESICAL. 

Beverages. — When  the  presence  of  vesical  calculus  has  been 
demonstrated  it  becomes  important  to  regulate  the  diet  so  as  to 
prevent,  if  possible,  aggravation  of  the  trouble.  Not  much  is  to  be 
hoped  from  the  action  of  any  solvents,  such  as  the  alkaline  waters 
or  lithia  salts,  upon  a  large  stone  already  formed,  but  diuretics  may 
certainly  do  much  to  prevent  recurrence  of  the  formation  by  con- 
trolling vesical  catarrh,  and  the  production  of  mucus  which  forms 
the  nucleus,  and  sometimes  a  considerable  part  of  many  stones. 
As  White  observes :  "  Our  object  should  then  be  to  make  the  urine 
as  bland  and  abundant  as  possible,  and  for  this  purpose  there  is 
nothing  better  than  milk  and  the  free  use  of  water  between  meals. 
The  particular  kind  of  water  to  be  used  is  of  minor  importance,  as 
the  most  noted  waters  in  the  treatment  of  stone  seem  to  have 
purity  as  their  chief  recommendation." 

The  still  spring  waters,  such  as  Poland,  Londonderry,  or  Bedford, 
may  be  prescribed,  or  the  waters  of  Vichy,  Saratoga,  or  Ems,  on 
the  principle  that  many  patients  will  drink  more  fluid  which  bears 
the  name  of  some  reputed  "  Spring  "  than  they  will  if  it  be  plain 
water. 

Paget  was  fond  of  trying  the  effect  of  an  exclusive  milk  diet 
before  advising  lithotomy.     The  milk   is  soothing,  and  while   it  is  a 


THE   URINARY   SYSTEM. 


477 


good  diuretic,  it  lessens  the  desire  for  frequent  micturition  which  is 
often  such  an  annoying  symptom  of  vesical  stone. 

The  occurrence  of  vesical  calculus  in  children  is  believed  by 
Cadge,  White,  and  others  to  be  directly  proportional  to  the  difficulty 
of  getting  abundant  milk.  It  is  therefore  much  commoner  among 
the  children  of  the  poor.  White  believes  that  "  diet  and  regimen,  at 
least  in  cities,  have  much  more  to  do  with  the  production  of  stone 
than  heredity,  climate,  water,  soil,  etc." 

Young  infants  should  not  be  given  lime  water  indefinitely  with 
their  milk. 

It  is  best  for  adults  to  relinquish  the  use  of  alcoholic  stimu- 
lants, but  if  this  is  not  feasible  light  Rhine  wine  or  still  Moselle 
is  admissible,  especially  if  neutralised  by  some  alkaline  table  water 
(Yeo).  Lager  beer  is  not  harmful,  and  a  little  dry  champagne  or 
a  light  hock  or  white  wine  may  be  taken.  All  the  heavier  clarets. 
Burgundy  and  sweet  wines  of  every  sort,  port,  sherry,  strong  beer, 
ale,  porter,  and  stout  are  forbidden.  Weak  tea  and  coffee  may  be 
drunk.  Only  such  beverages  should  be  allowed  as  contain  no  free 
acids  and  no  sugar,  and  those  having  the  greatest  diuretic  effect 
are  the  best. 

Foods. — All  highly  seasoned  and  irritating  articles,  like  vine- 
gar, pickles,  strong  condiments,  such  as  mustard,  should  be  rigidly 
forbidden,  as  well  as  anything  prone  to  excite  acid  dyspepsia. 

Among  patients  who  have  calculi  of  various  kinds  a  consider- 
able number  are  at  the  same  time  afflicted  with  obesity.  Such  per- 
sons must  be  especially  abstemious  in  regard  to  the  use  of  fats  and 
sugars.  Less  corpulent  persons  may  be  allowed  a  little  more  laxity 
in  this  regard. 

Other  substances  to  be  avoided  are  puddings  made  with  eggs 
and  sugar  and  containing  rice,  sago,  or  other  farinaceous  foods, 
suet  puddings,  pastry  of  all  kinds,  meat  fat,  and  fat  pork. 

Bread,  oatmeal,  hominy,  cracked  wheat,  corn-meal  bread,  custards, 
blancmange,  boiled  fish,  and  eggs  are  all  admissible. 

In  many  cases  total  abstinence  from  animal  food  for  a  week  or 
ten  days  is  followed  by  marked  improvement,  the  patient  living 
meanwhile  on  green  vegetables,  salads,  and  cooked  fruits  which  are 
not  too  acid,  such  as  apples,  not  sweetened,  but  flavoured  with  some 
bland  aromatic,  like  cinnamon,  nutmeg,  or  cloves.  In  other  cases  it 
may  not  be  necessary  to  withhold  meat  completely,  but  it  should 
always  be  taken  in  moderation,  not  more  than  once  a  day,  and  it 
should  be  rare,  lean,  and  thoroughly  masticated.  White  meat  of 
chicken  may  be  eaten. 

The  Carlsbad  dietary,  in  which  butter  and  sugar  in  all  forms  are 
rigidly  proscribed,  is  found. to  benefit  calculus  cases  even  more 
than  the  total  withdrawal  of  meat. 


478 


DIET   IN   DISEASE. 


The  above  directions  apply  to  the  treatment  of  most  varieties  of 
calculi,  and  not  to  any  one  kind  alone. 

In  elderly  people,  in  whom  such  disorders  are  relatively  common, 
the  functional  elimination  of  waste  from  the  body  is  considerably 
impaired.  For  such  persons,  as  well  as  for  those  who  live  sedentary 
lives,  it  is  important  to  abstain  from  overeating,  and  especially  from 
the  use  of  animal  food  in  excess. 

LITH^MIA.— URIC-ACID   DIATHESIS.— GRAVEL. 

Symptoms. — Lithaemia  is  a  condition  in  which  the  blood  con- 
tains an  excess  of  uric  acid  or  its  salts,  and  is  usually  productive  of 
such  symptoms  as  insomnia,  vertigo,  tinnitus  aurium,  disagreeable 
fulness  of  the  head,  and  general  "  nervousness."  The  urine  becomes 
loaded  with  nitrogenous  waste. 

When  uric  acid  appears  in  excess  as  a  sediment  in  the  urine  it  is 
very  desirable  that  its  formation  should  be  checked,  if  possible,  and 
that  any  crystals  already  deposited  in  the  kidneys  and  bladder  should 
be  dissolved  and  eliminated.  If  the  accumulation  continues,  the 
presence  of  crystals  ("  gravel  ")  gives  rise  to  attacks  of  renal  or  vesi- 
cal colic,  causing  intense  agonising  pain,  and  often  haematuria.  A 
majority  of  the  different  forms  of  calculi  are  composed  wholly  or  in 
part  of  uric  acid,  and  they  may  be  formed  in  any  part  of  the  genito- 
urinary canal,  which,  in  addition  to  the  other  symptoms,  may  possibly 
cause  ulceration  and  inflammation  of  the  mucous  membrane  or  seri- 
ous obstruction  to  the  outflow  of  the  urine.  The  exact  mode  of 
production  of  uric  acid  in  the  body  is  still  a  matter  of  uncertainty, 
but  it  is  undoubtedly  associated  with  nitrogenous  metabolism,  and 
the  acid  represents  an  imperfectly  oxidised  form  of  nitrogenous 
material.  The  final  destination  of  uric  acid  is  its  conversion  into 
urea,  but  from  lack  of  perfect  oxidation  in  the  tissues  this  process 
is  checked. 

Dietetic  Treatment. — The  indications  for  dietetic  treatment 
are  clearly,  therefore,  to  reduce  the  animal  foods  in  amount  or 
temporarily  withhold  them  altogether,  while  giving  large  quantities 
of  plain  water  and  of  waters  containing  potassium  or  lithium  salts 
to  aid  in  dissolving  the  uric  acid  already  existing  in  the  kidneys  or 
bladder,  and  promote  its  conversion  into  urea  and  hippuric  acid. 
The  same  rules  apply  to  renal  inadequacy  from  any  cause,  especially 
to  lessen  the  quantity  of  nitrogen  consumed. 

Although  the  acidity  of  the  urine  is  not  caused  by  uric  acid,  but 
by  acid  sodium  phosphate  (Na^POJ,  the  deposition  of  uric  acid  is 
accomplished  in  an  acid  menstruum,  and  it  is  well  to  reduce  the  urine 
temporarily  to  a  neutral  or  even  somewhat  alkaline  reaction.  This 
can  be  done  by  adapting  both  food  and  drink. 

Animal  food,  except  milk,  tends  to  make  the  urine  acid,  whereas 


THE    URINARY   SYSTEM. 


479 


milk  and  vegetable  food  favour  alkalinity.  In  speaking  of  the  lithic- 
acid  diathesis  in  children,  Fothergill  wrote  that  "  lean  meat,  raw 
meat  minced,  and  beef  tea  are  so  much  poison."  Lithaemic  head- 
aches will  often  cease  when  the  patient  stops  eating  butcher's  meat, 
cheese,  etc.,  if  excessive  indulgence  in  animal  food  has  been  the 
previous  habit.  Peptonising  such  food  makes  matters  even  worse, 
for  the  dyspepsia  which  often  accompanies  lithaemia  is  in  a  way  a 
conservative  process,  checking  the  digestion  of  animal  foods,  whereas 
the  predigested  foods  are  more  promptly  and  easily  carried  to  the 
overburdened  liver.  Some  lithaemic  patients  cannot  take  meat  well 
in  hot  weather,  but  can  do  so  at  other  seasons.  But  an  excessive 
meat  diet  cannot  be  regarded  as  the  sole  cause  of  lithsemia.  Other 
important  factors  are  concerned,  such  as  overeating  and  the  abuse 
of  saccharine  food,  which  causes  malfermentation,  deranges  the 
functions  of  the  liver,  and  alters  the  composition  of  both  blood  and 
urine. 

Murchison  declares  that  "  habitual  lithaemia  often  results  from 
the  patient  taking  more  food  than  can  be  converted  into  tissue  or 
disintegrated  in  the  liver,"  and  Sir  Henry  Thompson  expressed  his 
views  in  regard  to  sweets  thus  forcibly :  "  Sugar,  in  all  its  forms,  at 
every  meal,  and  wherever  met  with,  forbid  it  altogether,  ...  let 
fatty  matters,  butter,  cream,  and  the  fat  of  meat,  whether  simply 
cooked  or  in  combination  to  form  pastry,  be  taken  very  sparingly." 
This  is  the  practice  at  Carlsbad  also,  and  it  considerably  reduces  the 
work  of  the  liver  and  kidneys.  For  some  patients — especially  the 
obese — it  is  more  important  than  wholly  eliminating  meat  from  the 
regimen. 

Murchison,  who  was  among  the  first  to  advocate  a  rational  dietetic 
treatment  of  habitual  lithaemia,  forbade  all  saccharine  and  oleaginous 
food,  especially  "  made  dishes,"  and  highly-seasoned  foods,  sauces, 
rich  gravies,  etc.  In  severe  cases  he  insisted  upon  giving  up  simple 
amylaceous  foods  as  well,  and  forbade  the  eating  of  potatoes,  rice, 
sago,  fruits,  etc.,  and  bread  was  allowed  only  in  moderation.  In 
most  cases,  however,  vegetables  were  given  sparingly,  and  whitefish, 
poultry,  game  (if  not  too  rich),  and  eggs  were  included.  The  total 
quantity  of  food  was  reduced  considerably. 

Many  acids  contained  in  fresh  fruits,  such  as  benzoic  or  quinic 
acid,  have  a  favourable  solvent  action.  These  acids  are  found  in  the 
external  cuticle  of  fresh  fruits  and  vegetables,  which  may  be  eaten 
in  cases  of  gravel.  According  to  Lyman,  eating  raw,  unpeeled  apples 
in  considerable  quantities  supplies  potassium  salts,  which  tend  to  in- 
crease the  alkalinity  of  the  blood,  but  sweet  fruits,  pears,  grapes, 
plums,  strawberries,  etc.,  must  not  be  indulged  in. 

Patients  may  eat  abundantly  of  oatmeal,  wheaten  and  Graham 
bread  toasted,  macaroni,  fresh  young  peas,  string  beans,  Lima  beans, 
33 


gQ  DIET   IN   DISEASE. 

rice,  spinach,  asparagus,  celery,  lettuce,  and  other  salads,  except 
tomato  (without  oil).  Meat  should  not  be  eaten  oftener  than  once  a 
day.  Fresh  fish,  sweetbread,  poultry,  and  game  may  be  taken  spar- 
ingly in  ordinary  cases.     No  diet  can  be  rigidly  enforced  in  every 

case  alike. 

If  lithaemia  is  present  in  young  strumous  children  after  three  or 
five  years  of  age,  they  require  a  larger  proportion  of  fat.  They  may 
have  bread  and  butter  with  a  little  fat  bacon,  or  a  baked  potato  with 
butter,  and  puddings  of  bread,  crackers,  rice,  or  sago,  but  not  of  raw 
flour.  They  must  not  be  tempted  with  sweets.  They  often  have 
poor  appetites,  and  some  variety  must  be  prescribed,  or  they  will  lose 
weight  and  strength. 

Some  writers  are  disposed  to  attach  less  importance  to  dietetic 
errors  as  influencing  lithaemia  and  L.  C.  Gray  is  of  the  opinion  that 
the  cooking  is  far  more  important  than  the  composition  of  the  food. 
Reasonable  variety,  including  proteid  food,  should  be  allowed,  for 
"  lithsemics  do  best  on  plenty  of  well-prepared  food  in  the  greatest 
variety  according  to  the  seasons."  He  makes  much  use  of  milk,  and 
says  he  has  "  never  been  able  to  trace  a  single  case  to  overfeeding." 

Beverages. — Various  alkaline  mineral  waters  are  constantly 
prescribed  for  adults,  and  patients  who  can  afford  to  take  the  course 
are  benefited  by  the  baths  of  Carlsbad,  Vichy,  Neuenahr,  Ems,  etc., 
but  for  those  to  whom  travel  is  an  impossibility  and  whose  means 
do  not  allow  them  to  purchase  artificial  mineral  waters,  very  good 
substitutes  are  to  be  made  by  dissolving  sodium  carbonate  or  sodium 
phosphate  in  soda  water  or  sour  lemonade,  or  in  plain  water,  in  the 
proportion  of  from  one  to  two  drachms  in  three  or  four  pints,  to  be 
taken  in  the  course  of  the  twenty-four  hours,  or  two  to  five  grains  of 
the  carbonate  of  lithium  may  be  employed  in  the  same  way.  Eflfer- 
vescent  lithium  tablets  are  now  sold  which  may  be  added  to  a  tum- 
bler of  water  at  the  table  and  taken  with  meals. 

Solution  of  the  deposits,  or  at  least  the  prevention  of  their  in- 
crease, is  aided  by  the  free  drinking  of  Londonderry,  Buffalo,  or 
other  lithia  waters,  Vichy,  Waukesha,  etc.,  although  it  must  be  said 
of  most  so-called  lithia  waters  that  their  use  is  chiefly  that  of  pure 
water,  for  a  barrelful  would  have  to  be  drunk  to  obtain  an  ordinary 
medicinal  dose  of  lithium. 

Most  patients  do  better  without  alcohol  in  any  form.  They  may 
feel  the  loss  of  accustomed  stimulation  for  a  few  months,  but  they 
should  make  a  strong  effort  to  give  it  up  completely.  Malt  liquors 
and  sweet  wines,  champagne,  and  spirits  had  better  be  absolutely  for- 
bidden, but  if  necessary,  a  little  good  sound  claret  or  Scotch  whisky 
in  water  may  be  drunk. 

Gravel  is  much  less  common  among  habitual  beer  drinkers  than 
among  those  whose  daily  beverage  is  wine.     This  is  attributed  by 


THE   ALIMENTARY   CANAL.  481 

Moleschott  to  the  greater  acidity  and  larger  proportion  of  alcohol  in 
the  latter.*  On  the  contrary,  Ebstein  holds  that  beer  is  not  injurious 
in  lithiasis,  and  tea  also  has  some  reputation  in  checking  the  deposi- 
tion of  uric  acid.     Coffee  does  no  harm. 

GONORRHCEA. 

The  dietetic  treatment  of  gonorrhoea  consists  in  avoiding  all  stim- 
ulating food  and  drinking  bland  diluents. 

In  severe  cases,  and  in  cases  among  young  children  who  have  in 
some  manner  been  infected,  a  skimmed-milk  diet  should  be  ordered  at 
first.  Later,  light  farinaceous  articles,  stale  bread  and  butter,  milk, 
and  rice  puddings  should  be  added.  Patients,  for  fear  of  attracting 
attention  to  their  ailment,  are  often  unwilling  to  restrict  their  meals, 
but  they  must  avoid  acid  fruits,  all  highly  seasoned  and  fried  food,  con- 
diments, and  pastry.  Alcoholic  drinks  in  all  forms  are  absolutely  pro- 
hibited. Malt  liquors  are  especially  bad,  as  they  are  in  all  diseases 
of  the  urethra,  bladder,  or  prostate.  No  late  meals  should  be  taken. 
By  observing  these  directions  troublesome  chordee  and  ardor  uringe, 
so  apt  to  appear  in  the  first  fortnight,  may  be  prevented.  Large 
quantities  of  such  waters  as  soda.  Seltzer,  Apollinaris,  and  two  or 
three  quarts  of  plain  water  should  be  drunk.  The  fluid  dilutes  the 
urine,  diminishes  the  danger  of  cystitis,  and  has  the  additional  ad- 
vantage of  decreasing  the  appetite. 


DIET    IN    DISEASES   OF  THE   ALIMENTARY   CANAL. 

Diet  in  Abnormal  Dentition. 

In  abnormal  dentition  in  children  the  food  is  imperfectly  masti- 
cated, and  gastric  dyspepsia  or  gastric  catarrh  may  follow.  If  den- 
tition is  delayed  and  the  teeth  are  imperfect,  as  in  the  case  of  rickets, 
scrofula,  tuberculosis,  or  any  protracted  disease  involving  nutrition, 
the  diet  should  be  made  as  nourishing  as  possible,  and  meat,  eggs, 
milk,  cream,  and  broths  should  be  given  in  addition  to  cereals.  Cod- 
liver  oil  is  usually  prescribed  with  benefit.  There  is  no  one  food  of 
special  value  for  retarded  dentition  on  account  of  its  containing  the 
lime  salts  of  the  teeth,  and  the  chief  reliance  for  this  purpose  must 
be  placed  in  building  up  general  nutrition. 

In  all  cases  of  dyspepsia,  gastric  catarrh,  rickets,  or  syphilis  the 
teeth  must  be  carefully  examined  before  prescribing  special  dietetic 
treatment. 

If  the  teeth  are  broken  or  irregular  all  solid  food  should  be  care- 
fully prepared  by  mincing  or  otherwise  reducing  it  to  a  form  requir- 
ing but  little  mastication.  In  a  young  child  a  sore  mouth  from 
swollen  gums  is  often  overlooked  as  a  cause  of  anorexia. 


482 


DIET   IN   DISEASE. 


The  perfection  with  which  false  teeth  are  now  fitted  has  done 
much  to  improve  the  digestion  of  adults  and  to  add  to  the  comfort 
and,  no  doubt  in  some  instances,  prolong  the  life  of  the  aged. 

Catarrhal  Stomatitis. 

Catarrhal  stomatitis  is  a  simple  inflammation  of  the  mucous  mem- 
brane of  the  mouth  which,  among  other  causes,  may  be  excited  by 
taking  food  or  drink  at  either  extreme  of  temperature.  Food  which 
is  very  acid  or  too  highly  seasoned  with  condiments  may  cause  it, 
so  also  may  excessive  drinking  and  smoking. 

No  special  diet  is  required  beyond  giving  food  which  is  easily 
swallowed  and  which  is  free  from  the  above  objections. 

When  the  disease  occurs  in  infants  their  diet  must  be  regulated 
according  to  the  directions  for  feeding  detailed  under  the  heading 
Infant  Feeding. 

In  gangrenous  stomatitis  the  mouth  may  become  too  sore  to  ad- 
mit of  swallowing,  in  which  case  food  must  be  given  by  the  rectum 
(see  Nutrient  Enemata,  page  375).  Otherwise  small  quantities  of 
fluid  food  must  be  ordered  at  frequent  intervals.  Concentrated  meat 
broths,  egg  albumen,  meat  juice,  and  milk  are  to  be  taken  at  hourly 
intervals.  If  the  stomach  is  irritable  this  food  should  all  be  predi- 
gested  with  pancreatin.  Alcohol,  preferably  in  the  form  of  brandy, 
should  be  frequently  given  to  the  limit  of  toleration. 

The  above  directions  apply  also  to  cases  of  inflammation  of  the 
mouth  and  pharynx  caused  by  corrosive  poisons,  such  as  carbolic 
acid,  ammonia,  etc. 

TONSILITIS   AND   QuiNSY. 

These  diseases  require  no  special  care  in  the  acute  stage  beyond 
giving  food  in  such  fluid  form  as  can  be  most  easily  swallowed.  The 
pain  caused  by  this  act  is  often  so  extreme  that  it  is  advisable  to  con- 
centrate all  food,  to  save  the  number  of  necessary  acts  of  degluti- 
tion. Meat  juice,  peptonoids,  beaten  eggs,  and  brandy  may  be  added 
to  good  milk.  Plain  vanilla  ice  cream  may  be  given.  Its  coldness 
is  sometimes  soothing  to  the  pharynx. 

Holding  cracked  ice  in  the  mouth  before  swallowing  will  some- 
times annul  the  pain  momentarily,  or  in  extreme  cases  the  pharynx 
and  tonsils  may  be  sprayed  with  cocaine,  and  the  period  of  tempo- 
rary anaesthesia  may  be  utilised  for  swallowing  considerable  nour- 
ishment. This  is  rarely  necessary,  for  unless  the  patient  is  emaciated 
by  previous  serious  illness,  he  is  not  apt  to  be  in  need  of  much  food 
for  a  day  or  two.  In  bad  cases  of  suppurative  tonsilitis  the  strength 
suffers  more,  and  stimulants  may  be  given  by  the  rectum  if  degluti- 
tion is  impossible. 

After  all  forms  of  tonsilitis  there  is  apt  to  be  considerable  anaemia, 


THE   ALIMENTARY   CANAL. 


483 


and  the  patient  for  a  week  or  two  should  eat  abundantly  of  animal 
food.  Eggnog  and  milk  punches  are  often  needed  for  the  first  few 
days  of  (convalescence. 

Dysphagia. 

When  the  normal  mechanism  of  swallowing  the  food  is  disturbed 
the  condition  is  called  dysphagia.  It  is  commonly  due  to  one  of  the 
following  causes  :  Spasm  of  the  muscles  of  mastication  (trismus) ; 
inflammations  of  the  mouth,  tongue,  pharynx,  or  tonsils;  diphtheria; 
tubercular,  cancerous,  or  syphilitic  pharyngeal  disease;  retropha- 
ryngeal abscess  ;  stricture  or  carcinoma  of  the  oesophagus  ;  paralyses 
(sometimes  of  central  origin) ;  operations  upon  or  near  the  pharynx  ; 
or  the  wearing  of  an  O'Dwyer  tube  in  the  larynx. 

The  devices  employed  to  enable  the  patient  to  overcome  pain  or 
difficulty  in  swallowing  his  food  should  include  reduction  of  the 
efforts  at  swallowing  to  a  minimum.  A  raw  egg  or  oyster  may  some- 
times be  gulped  down  by  a  single  act  when  the  dread  of  pain  from 
more  repeated  effort  deters  the  patient  from  taking  other  food. 
Whatever  is  given  should  therefore  consist  of  concentrated  nutriment 
in  a  smooth,  semisolid  or  gelatinous  form.  Wine  jelly  may  be  re-en- 
forced with  beef  peptonoids  or  egg  albumen,  and  custards  may  be 
thickened  with  farinaceous  material  to  a  consistence  which  will  enable 
them  to  be  quickly  swallowed. 

When  patients  are  unable  to  swallow,  an  oesophageal  tube  is  in- 
serted for  feeding,  which,  however,  should  be  a  catheter  of  small 
calibre  (English  8  to  18),  and  which  need  not  be  passed  very  far 
down  into  the  cesophagus.  If  necessary,  a  2-  or  4-per-cent  solu- 
tion of  cocaine  may  be  first  applied  to  the  pharynx  to  relieve  pain 
and  irritation.  The  fluid  food — eggnog,  broths,  thick  gruels,  milk, 
etc. — is  poured  into  the  tube  through  a  funnel. 

When  the  tube  feeding  connot  be  practised,  it  becomes  necessary 
to  resort  to  rectal  enemata,  or  both  methods  may  be  employed  in 
order  to  reduce  the  number  of  feedings  through  the  painful  throat. 

Delavan  calls  attention  to  the  important  fact  that  the  point  of 
greatest  irritation  is  often  the  palatine  arches,  and  by  passing  the 
tube  through  the  nose  into  the  pharynx  behind  them  this  difficulty 
is  neatly  avoided. 

In  hopeless  cases  of  cancer  or  of  tubercular  ulceration  of  the 
epiglottis,  tonsils,  etc.,  which  are  so  intensely  painful,  it  may  be 
justifiable  to  perform  gastrotomy  in  order  to  place  food  directly  in 
the  stomach.  This  is  certainly  preferable  to  letting  the  patient  starve 
to  death  because  he  finds  the  agony  of  swallowing  is  even  worse  than 
the  pangs  of  hunger. 


484 


DIET   IN   DISEASE. 


Stricture  and  Carcinoma  of  the  CEsophagus. 

In  diseases  of  the  oesophagus  which  render  swallowing  difficult 
all  food  must  be  given  in  semisolid  or  fluid  form.  Many  vegetable 
substances  can  be  made  mio  purees,  which  can  be  strengthened  by 
meat  extracts,  peptonoids,  or  beef  meal.  Milk,  in  its  various  forms, 
is  always  soothing,  and  it  may  be  the  only  food  which  the  patient 
can  take. 

Richardson  states  that  in  oesophageal  stricture  cold  food  relaxes 
the  circular  fibres  of  the  oesophagus  and  dilates  its  lumen,  whereas 
hot  food  has  an  opposite  effect.  In  some  hysterical  patients  this 
may  prove  true,  but  in  most  cases  of  genuine  stricture  or  occlusion 
the  temperature  of  the  ingested  food  makes  but  little  difference. 
When  the  occlusion  or  the  difficulty  or  pain  in  deglutition  becomes 
so  great  that  the  patient  suffers  from  inanition — as,  for  example,  after 
corrosive  poisons  have  been  swallowed — he  must  be  fed  by  nutrient 
enemata.  Should  the  trouble  not  be  overcome,  a  gastric  fistula  must 
be  made,  and  the  patient  is  to  be  fed  by  this  means. 

Feeding  through  a  Gastric  Fistula. — When  a  gastric  fistula 
is  made  the  wound  may  be  left  open  with  a  drainage  tube,  or,  what 
is  better,  a  permanent  hard-rubber  or  metallic  tube  is  inserted,  hav- 
ing a  double  flange,  like  a  spool.  The  tube  is  nickei-plated  to  pre- 
vent erosion  by  the  acid  gastric  juice.  The  lumen  may  be  a  third  of 
an  inch  in  diameter,  and  when  not  in  use  it  is  kept  closed  by  a  cork. 
When  the  patient  is  to  be  fed  he  must  lie  upon  his  back.  The  cork 
is  removed,  the  tube  cleansed  with  a  syringeful  of  warm  water,  and 
through  a  glass  funnel,  to  which  is  attached  an  inch  or  two  of  rubber 
tubing,  fluid  food  is  poured  directly  through  the  fistulous  open- 
ing into  the  stomach.  If  desirable,  lavage  may  be  performed  in  a 
similar  manner.  Any  kind  of  food  may  be  given  which  the  patient  is 
able  to  digest.  Even  small  pieces  of  chopped  meat  can  be  pushed 
into  the  stomach  with  a  glass  rod  or  forceps.  Medicines  are  conve- 
niently given  through  the  same  opening.  When  the  fistula  has  been 
made  for  other  cause  than  malignant  disease  the  spool  may  be  worn 
indefinitely  with  no  other  inconvenience  than  that  attending  the  pe- 
culiar process  of  feeding.  I  have  recently  seen  a  patient  who  has 
worn  such  a  one  for  several  years,  and  who  goes  about  like  other 
men,  excepting  that  he  takes  his  meals  in  private  and  feeds  himself 
while  lying  on  his  back. 

FOREIGN   BODIES   SWALLOWED. 

When  foreign  bodies  have  been  accidentally  swallowed,  such  as 

coins,  buttons,  safety  or  other  pins,  large  cherry,  plum,  or  other 

fruit  stones,  fish  bones,  chicken  bones,  or  pieces  of  clam  or  oyster 

shells,  if  the  patient  is  seen  within  two  or  three  hours,  the  object 


THE   ALIMENTARY   CANAL.  485 

having  passed  beyond  the  reach  of  the  finger  or  oesophageal  pro- 
bang,  an  emetic  may  be  given.  If  this  fails  to  return  the  foreign 
body  from  the  stomach,  the  patient  should  eat  large  quantities  of 
bread,  oatmeal,  or  potatoes.  The  plan  of  this  treatment  is  to  fur- 
nish a  bulk  of  faecal  matter,  which  in  the  intestines  may  envelop  the 
pin  or  bone,  and  prevent  its  sharp  or  roughened  ends  from  injuring 
the  mucous  membrane.  Six  or  eight  hours  later  a  dose  of  castor  oil 
should  be  given.  By  this  means  many  dangerous  objects  may  be 
safely  voided.  If  the  foreign  body  does  not  appear  after  the  oil  has 
acted,  the  treatment  should  be  repeated  next  day,  and  the  stools 
must  be  carefully  watched  until  it  is  recovered.  Experience  has 
shown  that  the  search  should  not  be  abandoned  for  at  least  eight  or 
ten  days.  Men  who  earn  a  precarious  livelihood  by  publicly  exhib- 
iting themselves  as  possessing  "  iron  stomachs,"  and  who  swallow 
broken  glass,  coins,  nails,  etc.,  take  considerable  risk  from  exciting 
grave  injury  or  peritonitis,  but  by  eating  the  foreign  bodies  only 
when  the  stomach  is  nearly  full,  and  by  following  the  treatment  out- 
lined above,  they  manage  to  escape  death. 

Indigestion  and  Dyspepsia. 

Symptoms. — Indigestion  and  dyspepsia  are  terms  which  refer 
essentially  to  functional  slight  and  often  temporary  derangement  of 
the  digestive  system,  although  these  conditions  may  result  from 
many  varieties  of  disease,  especially  from  fever  due  to  almost  any 
cause.  The  terms  are  used  somewhat  vaguely  to  include  a  number 
of  minor  symptoms,  such  as  weight  and  oppression  at  the  epigas- 
trium and  praecordium,  eructations,  "water  brash,"  palpitations,  ver- 
tigo, headache,  modified  taste  and  thirst  sensations,  loss  of  appetite 
or  morbid  craving  for  certain  indigestible  articles  of  food,  flatulency, 
hiccough,  and  sometimes  nausea,  heartburn,  pain  referred  to  the 
cardiac  end  of  the  stomach,  lassitude,  irritability,  drowsiness  or  rest- 
lessness, and  despondency.  As  Sir  H.  Thompson  says:  "The  word 
indigestion  denotes  not  a  disease,  but  an  admonition." 

Fothergill  wrote:  "  If  it  were  not  for  the  protection  of  indiges- 
tion, of  which  many  so  bitterly  and  ungratefully  complain,  the  lives 
of  a  large  number  of  individuals  would  not  attain  their  furthest  po- 
tential expansion." 

Many  of  these  symptoms,  especially  those  referable  to  the  nerv- 
ous and  vascular  systems,  are  explained  by  the  belief  that  morbid 
products  which  closely  resemble  poisonous  alkaloids  in  their  action 
(as  indeed  in  their  composition),  and  which  are  called  ptomaines  or 
leucomaines,  are  easily  absorbed,  and  produce  effects  varying  in  in- 
tensity from  slight  headache  to  the  collapse  of  violent  ptomaine 
poisoning  (page  350).  Other  symptoms  are  doubtless  due  to  imper- 
fect elimination  of  waste  matter  of  food  or  "ashes  "  from  the  system. 


486 


DIET    IN   DISEASE. 


Bauer  says:  "It  is  beyond  doubt  that  insufficient  secretion  is  the 
essential  cause  of  most  dyspeptic  symptoms  as  they  appear  in  vari- 
ous disorders  of  the  stomach." 

In  severe  fevers  and  conditions  of  advanced  anaemia  or  gastric 
catarrh  the  stomach  secretes  chiefly  a  ropy  alkaline  mucous  fluid, 
with  little  or  no  true  gastric  juice. 

As  a  rule,  the  acid  gives  out  before  the  pepsin,  and  a  deficiency 
of  acid  is  a  very  common  condition,  especially  in  anaemia.  Anaemia 
produced  experimentally  by  repeated  bleeding  of  animals  will  cause  it. 

Chronic  hyperaemia  and  inflammation  of  the  stomach  excited  by 
coarse  irritating  food  have  the  same  result,  and  the  free  acid,  if  se- 
creted, is  neutralised  by  abundant  mucus. 

Deficiency  of  hydrochloric  acid  in  the  gastric  juice  has  a  three- 
fold effect:  i.  Failure  to  digest  proteids ;  2,  failure  to  arrest  mal- 
fermentation  or  putrefactive  changes  in  the  food  ;  3,  failure  to  ex- 
cite gastric  peristalsis,  so  that  the  food  lingers  too  long  in  the  stom- 
ach. Other  causes  of  delay  may  be  found  in  too  large  a  bulk  of  food, 
lack  of  peristalsis,  and  obstruction  through  stenosis  of  the  pylorus 
without  corresponding  increase  in  contractile  power  of  the  stomach. 

Gases. — The  normal  gases  of  the  stomach  are  those  of  atmos- 
pheric air;  but  food  which  is  improperly  fermenting  is  capable  of 
evolving  others,  and  those  which  have  been  determined  by  analysis 
of  eructations  are  CO^jH^tO^N^jCH^  (marsh  gas)  C^H^  (olefiant  gas). 

Ewald  reports  a  case  in  which  sufficient  marsh  gas  was  evolved 
from  the  stomach  to  burn  with  a  pale-yellow  flame. 

Some  degree  of  lactic-acid  fermentation  may  be  a  normal  accom- 
paniment of  gastric  digestion,  but  the  process  is  easily  carried  too 
far;  butyric  acid  develops,  and  gases  are  evolved.  This  action  re- 
sembles that  produced  outside  the  body  when  decomposing  albumin 
comes  in  contact  with  saccharine  substances. 

Distention  of  the  stomach  and  intestine  with  gas  interferes  with 
the  free  play  of  the  diaphragm  in  the  respiratory  movements,  and 
since  the  heart  lies  upon  its  side,  separated  from  the  stomach  only  by 
the  diaphragm,  an  inflated  stomach  compresses  and  displaces  the 
heart,  interfering  with  its  rhythm  and  force  and  causing  palpitations. 
The  latter,  in  connection  with  impeded  extent  of  movement  of  the 
diaphragm,  produces  dyspnoea,  especially  on  exertion. 

Pain  is  a  very  frequent  accompaniment  of  dyspepsia.  It  is  usu- 
ally of  a  dull  aching  variety,  but  is  sometimes  sharp  and  acute.  It 
is  often  erroneously  referred  to  the  heart,  but  it  is  due  rather  to 
hyperaesthesia  of  the  stomach  wall,  excited  by  products  of  imperfect 
digestion. 

In  all  diseases  of  the  stomach  the  retention  of  any  particles  of 
undigested  food  gives  rise  to  irritation  and  malfermentation,  which 
still  further  complicates  the  diseased  condition  of  the  organ  itself 


THE   ALIMENTARY   CANAL. 


487 


and  interferes  with  its  proper  action  upon  fresh  quantities  of  food. 
This  may  be  occasionally  relieved  by  vomiting  or  by  the  ingestion 
of  some  simple  fluid  which  will  aid  in  washing  the  stomach  contents 
onward  into  the  intestine. 

iEtiology,  Idiosyncrasies. — Personal  idiosyncrasy  is  a  very 
potent  factor  in  dyspepsia.  Not  only  do  individuals  vary  from  one 
another  in  this  regard,  but  the  same  individual  varies  at  different 
periods,  in  different  stages  of  health,  or  at  different  ages.  One  not 
uncommonly  observes  persons  who  are  most  confirmed  dyspeptics  at 
home,  but  who  when  at  sea  are  able  to  eat  and  digest  all  manner  of 
richly  cooked  and  thoroughly  indigestible  food  without  either  nausea 
or  discomfort,  only  to  return  to  their  dyspepsia  on  shore.  On  the 
other  hand,  many  persons  whose  digestion  is  normal  at  home  are 
made  constipated  and  dyspeptic  by  the  lack  of  exercise  and  by  other 
conditions  at  sea,  even  though  they  be  never  "  seasick."  How  often 
do  dyspeptics  who  have  been  long  kept  upon  a  rigid  regimen  break 
away  from  all  restraint  and  give  astonishing  accounts  of  the  for- 
bidden articles  which  they  have  suddenly  discovered  they  can  eat  for 
a  time  with  impunity !  One  who  cannot  digest  the  most  tender 
mouthful  of  prepared  meat  or  a  crust  of  dry  bread  will  thrive  upon 
enormous  quantities  of  nuts  and  oranges,  another  requires  a  prepos- 
terous quantity  of  pickles  or  of  Cayenne  pepper  to  stimulate  the 
sluggish  digestion  into  any  sort  of  activity,  and  another  lives  largely 
upon  raw  apples ! 

Many  people  cannot  eat  strawberries  without  attacks  of  heart- 
burn and  dyspepsia,  while  for  others  they  are  very  wholesome  food. 
Some  persons  cannot  eat  cauliflower  without  exciting  dyspepsia,  and 
for  others  the  use  of  melted  butter  invariably  brings  on  such  an 
attack,  while  butter  spread  upon  bread  does  not.  Others  exhibit  in- 
tolerance for  twice-cooked  meats,  new  bread,  potatoes,  sweet  jams 
of  any  kind,  etc.  (see  Idiosyncrasies  in  Regard  to  Food,  page  364). 

Other  Causes. — Fats  and  greasy  foods  set  up  butyric-acid  fer- 
mentation which  causes  heartburn,  regurgitation,  and  a  rancid  dis- 
agreeable taste. 

Sweets  and  raw  or  insufficiently  cooked  starches  cause  lactic-acid 
and  other  fermentations,  with  flatulence. 

Combinations  of  certain  foods  almost  always  disagree,  as,  for 
example,  sweets  and  acids,  fruits  and  beer,  ice  cream  and  beer,  milk 
and  cherries,  milk  and  crabs. 

Dyspepsia  is  often  caused  by  the  continued  abuse  of  irritants, 
such  as  alcohol  and  highly  seasoned  food,  pickles,  mustard,  Cayenne. 

Tobacco  and  strong  tea  and  coffee  have  a  depressing  action  upon 
the  nervous  force  of  the  stomach. 

To  enumerate  all  the  various  substances  which  may  at  some  time 
or  other  cause  indigestion  would  be  to  include  practically  the  entire 


488 


DIET    IN   DISEASE. 


list  of  foods.     Each  new  case  must  be  separately  studied,  and  gen- 
eral rules  admit  of  many  exceptions. 

Balfour  concisely  sums  up  the  relations  of  food  to  enfeebled 
stomach  digestion  by  saying :  "  Three  things  greatly  disturb  gastric 
comfort — too  large  a  meal,  too  short  an  interval  between  the  meals, 
and,  lastly,  the  ingestion  of  food  into  a  stomach  still  digesting." 

Examination  of  the  Patient. — It  is  important  at  the  outset 
to  understand  all  the  patient's  habits  of  daily  life,  the  amount  of 
sleep  and  exercise  taken,  the  hours  of  meals  and  quantity  and  quality 
of  food  eaten,  habits  of  drinking  or  smoking,  the  habit  of  the  bowels, 
condition  of  the  stools,  and  the  nature  of  any  irregularity — the  habit 
of  eating  too  fast  or  taking  too  much  or  too  little  fluid  with  the 
meals.  The  condition  of  the  teeth  and  tongue  and  breath  must  also 
be  observed,  and  in  obscure  cases  the  possible  existence  of  sources 
of  reflex  irritation,  like  ovarian  disease,  must  be  investigated.  The 
proper  cooking  of  the  food  should  be  insisted  upon.  Thorough 
cross-examination  in  regard  to  all  of  these  conditions  may  reveal 
habits  not  suspected  by  the  patient  to  be  injurious,  and  which  may 
be  easily  corrected. 

Slow  Hating'. — A  simple  explanation  of  the  normal  physiology 
of  digestion  will  often  interest  an  intelligent  patient  and  secure  his 
hearty  co-operation  in  methods  suggested  for  his  cure,  which  other- 
wise he  would  find  extremely  irksome.  He  should  understand  that 
digestion  commences  at  once  in  the  mouth  by  the  proper  preparation 
there  of  all  food  and  the  digestion  of  starch  in  particular,  and  that 
the  practice  of  slow  eating  gives  time  not  only  for  more  thorough 
mastication,  but  also  for  more  abundant  secretion  of  the  necessary 
digestive  fluids,  saliva,  and  gastric  juice.  Very  slow  eaters  are  far 
less  often  dyspeptic  than  those  who  "  eat  and  run."  The  sign 
"Quick  Lunch,"  so  commonly  displayed  in  restaurants  in  business 
quarters  of  active  American  cities,  has  contributed  much  toward 
earning  for  Americans  the  title  of  a  "  Nation  of  Dyspeptics,"  for  a 
meal  quickly  served  is  too  quickly  eaten  as  well.  A  dyspeptic  child 
may  be  taught  to  count  between  his  mouthfuls. 

Solid  food  insufficiently  masticated  passes  into  the  stomach  too 
dry  and  in  too  large  masses  for  the  gastric  juice  to  act  upon  it 
promptly,  and  stomach  digestion  is  greatly  retarded.  In  persons 
with  feeble  digestive  power  who  eat  hastily,  pieces  of  meat  and 
tough  vegetable  fibres  often  appear  in  the  stools  wholly  unaltered. 
The  sense  of  taste  may  be  utilised  in  order  to  prolong  mastication 
by  savoury  cooking.  It  also  stimulates  the  secretion  of  saliva  and 
gastric  juice.  In  such  cases,  as  well  as  in  those  in  which  the  teeth 
are  absent  or  defective,  it  is  well  to  prohibit  all  food  which  is  not 
completely  subdivided  or  tender,  as,  for  example,  tough  meats  and 
stringy  or  fibrous  vegetables. 


THE   ALIMENTARY   CANAL. 


489 


Pain. — In  nervous  dyspepsia  pain  exists  as  a  prominent  symp- 
tom, and  is  often  independent  of  the  quality  of  the  food — even  a 
mouthful  of  water  may  cause  it  (Henry),  but,  as  a  rule,  fatty  and 
acid  foods  excite  it,  and  must  therefore  be  avoided.  The  appetite, 
too,  varies  greatly — it  may  wholly  fail  at  one  time,  and  return  in  an 
exaggerated  form  at  another.  Decker  reported  the  case  of  a  patient 
who  was  uniformly  awakened  from  sleep  by  such  excessive  hunger 
that  he  was  obliged  to  take  a  hearty  luncheon  in  the  middle  of  the 
night. 

EXAMINATION   OF   THE   STOMACH    CONTENTS. 

In  all  cases  of  protracted  dyspepsia  which  do  not  yield  readily  to 
dietetic  treatment  and  proper  medication  it  becomes  important  to 
ascertain  the  exact  condition  of  the  stomach  and  gastric  juice,  and 
for  this  purpose  several  ingenious  clinical  tests  have  been  devised. 
These  tests  are  applied  to  ascertain — I.  The  degree  of  acidity  of  the 
gastric  juice.  II.  The  vigour  of  peristaltic  action  of  the  stomach 
wall.     III.  The  rate  of  absorption  from  the  mucous  membrane. 

I.  To  determine  the  acidity  of  the  gastric  juice,  a  fresh  specimen 
must  be  obtained  for  analysis.  There  are  several  means  of  doing 
this: 

1.  By  a  sponge. 

2.  By  the  stomach  bucket. 

3.  By  siphonage. 

1.  To  obtain  gastric  juice  with  a  sponge  the  patient  must  swallow 
a  small  piece  of  one  tied  firmly  to  a  silken  cord.  When  the  sponge 
reaches  the  stomach  it  becomes  saturated  and  swollen  with  the  gas- 
tric juice.  It  is  then  carefully  withdrawn,  and  the  few  drops  of 
juice  squeezed  from  it  are  tested  for  hydrochloric  acid.  This  method 
is  less  disagreeable  to  some  patients  than  swallowing  a  stomach  tube, 
but  the  sponge  becomes  coated  with  oesophageal  mucus  and  saliva, 
which  interferes  with  the  accuracy  of  the  test.  Its  value  is  positive, 
not  negative. 

2.  Einhorn  has  devised  a  stomach  bucket  about  the  size  and 
shape  of  a  small  olive  or  a  gelatin  capsule,  which  is  easily  swal- 
lowed. It  is  attached  to  a  silken  cord,  by  which  it  is  drawn  up  again, 
like  the  sponge.  It  is  made  of  non-corrosive  metal,  and  is  so  small 
and  smooth  that  if  it  were  lost  it  could  do  no  harm,  but,  like  a  cherry 
pit,  it  would  be  voided  with  the  stools.  I  have  found  its  use  open 
to  the  same  objection  with  the  sponge — namely,  that  it  gathers  mucus 
and  swallowed  saliva  from  the  oesophageal  wall,  which  neutralises 
any  gastric  juice  which  it  may  contain.  It  also  sometimes  catches 
at  the  cardiac  end  of  the  stomach  and  causes  the  patient  some  dis- 
comfort, although  this  may  be  overcome  by  getting  him  to  swallow 
as  the  bucket  is  withdrawn.  Sometimes,  however,  it  brings  up  a 
•'bucketful  "  of  acid  juice  very  satisfactorily. 


^^  DIET   IN   DISEASE. 

3.  By  far  the  best  method  of  obtaining  gastric  juice  is  by  siphon- 
age.  The  stomach  tube  is  inserted  in  the  manner  described  for  gas- 
tric lavage,  and  the  contents  of  the  stomach  are  withdrawn  in  suf- 
ficient quantity  to  yield  a  satisfactory  analysis. 

Some  hysterical  dyspeptics  vomit  so  readily  that  the  gastric  juice 
may  be  obtained  from  the  ejecta  at  any  time. 

TEST    MEALS. 

The  composition  of  the  gastric  juice  is  best  determined  by  fo'- 
lowing  lavage  by  a  test  meal.  After  a  definite  period  the  stomach 
tube  is  again  introduced  and  a  sample  of  the  stomach  contents  is 
withdrawn,  filtered,  and  examined  for  hydrochloric  acid  and  pepsin. 
If  desired,  other  tests  may  be  made  for  rennet  ferment,  carbohy- 
drates, peptones,  albuminoses,  lactic  acid,  phosphates,  and  fatty 
acids.  The  test  for  hydrochloric  acid  is  the  only  one  commonly 
applied  for  clinical  purposes,  and  to  aid  the  selection  of  proper 
diet,  the  others  belong  rather  to  special  research. 

The  best  test  meals  are  Riegel  and  Leube's  test  dinner,  and  a 
modification  of  this,  known  as  Ewald's  test  breakfast,  which  is  easier 
to  eat  and  does  not  obstruct  the  stomach  tube,  although  it  stimu- 
lates the  digestive  activity  of  the  stomach  somewhat  less.  The 
stomach  contents  should  be  withdrawn  for  examination  one  hour 
after  the  breakfast,  but  between  four  and  five  hours  after  the 
dinner. 

Riegel  and  Leube's  test  dinner  consists  of— 

Beef  soup 400  cubic  centimetres. 

Beefsteak 200      "  " 

"White  bread 50      "  " 

Water 200     "  " 

Ewald's  test  breakfast  is  35  to  70  cubic  centimetres  of  wheaten 
bread  (one  or  two  white  coffee  rolls)  with  300  cubic  centimetres  of 
water  or  weak  tea  without  sugar  or  milk.  When  the  contents  of  the 
stomach  are  withdrawn  one  hour  after  ingestion  of  this  meal  its  total 
quantity  should  be  found  reduced  to  20  to  40  cubic  centimetres. 

In  withdrawing  the  contents  of  a  stomach  after  a  test  meal  the 
same  tube  is  used,  and  in  the  same  manner,  as  that  employed  for 
lavage,  described  on  page  513.  It  is  important  that  its  introduc- 
tion should  not  be  accompanied  by  violent  retchkig,  for  when  this 
takes  place  bile  is  very  apt  to  be  regurgitated  into  the  stomach  and 
neutralise  its  acid  contents,  rendering  subsequent  tests  useless. 
The  retching  may  be  overcome  by  painting  or  spraying  the  pharynx 
with  a  2-  or  4-per-cent  solution  of  cocaine,  or,  as  Stewart  recom- 
mends, by  allowing  the  patient  to  swallow  a  few  drops  of  the  solu- 
tion, to  anaesthetise  the  oesophagus.     The  use  of  a  rather  stiff  tube. 


THE   ALIMENTARY  CANAL. 


491 


quickly  inserted,  diminishes  the  liabiHty  to  retching.  The  tube 
should  not  be  lubricated  when  used  for  the  test  meals,  but  it  may 
be  wetted.  The  gastric  contents  may  be  forced  out  through  the 
tube  by  directing  the  patient  to  forcibly  expire,  thereby  compres- 
sing the  stomach  by  the  abdominal  muscles,  and  simultaneously 
the  epigastrium  should  be  firmly  compressed  by  the  hands.  It  is 
also  obtained  by  attaching  to  the  stomach  tube  the  bulb  of  a  David- 
son syringe  or  a  suction  bottle  such  as  that  in  common  use  for  aspi- 
rating the  thorax  or  abdomen.  If  no  fluid  flows,  a  little  air  or  warm 
water  may  be  forced  through  the  tube  to  cleanse  the  obstructed 
fenestra. 

Dujardin-Beaumetz  gives  a  test  breakfast  of  coffee  or  tea  with 
milk  and  a  little  sugar,  and  one  or  two  plain  rolls;  no  butter.  The 
fluid  must  not  exceed  a  pint.  The  normal  stomach  digests  such  a 
meal  without  sensation.  If  within  two  hours  there  is  a  sensation  of 
heat  in  the  stomach  or  burning  and  acidity,  hyperacidity  is  present. 
If  there  is  eructation  of  gas,  fulness  and  weight  at  the  stomach, 
then  there  is  diminished  or  hypoacidity. 

If  pain  occurs  within  fifteen  minutes  with  increasing  intensity 
there  is  probably  some  organic  lesion.  In  hyperacidity,  moreover, 
Beaumetz  says  that  the  burning  is  worse  three  to  four  hours  after 
eating,  and  is  commonest  in  the  middle  of  the  night.  It  is  often 
relieved  by  ingestion  of  food,  which  temporarily  dilutes  the  acid. 
He  urges  dyspeptics  to  sleep  on  the  right  side,  to  aid  the  passage 
of  food  through  the  then  dependent  pylorus. 

TEST   FOR   TOTAL   ACIDITY   OF   THE   GASTRIC   JUICE. 

Before  testing  for  the  presence  of  free  hydrochloric  acid,  the 
total  acidity  of  the  stomach  may  be  obtained,  which  is  the  combined 
acidity  produced  by  HCl  and  lactic  or  other  organic  acids  com- 
monly developed  by  malfermentation.  This  total  acidity  should 
equal  normally  40  to  65  (Ewald),  which  represents  "  the  number  of 
cubic  centimetres  of  test  solution  required  to  exactly  neutralise 
100  cubic  centimetres  of  gastric  filtrate  "  (D.  D.  Stewart.)  The  test 
solution  is  prepared  as  follows  : 

"  Four  grammes  of  NaOH  dissolved  in  one  litre  of  distilled  water 
is  used  for  neutralisation  ;  each  cubic  centimetre  of  this  solution 
will  exactly  neutralise  0.00264  gramme  of  absolute  hydrochloric 
acid.  The  number  of  cubic  centimetres  so  used  multiplied  by 
0.00364  equals  the  percentage  of  HCl  contained  in  100  cubic  centi- 
metres of  the  gastric  filtrate  "  (Stewart). 

CHE.MICAL   TEST   FOR    FREE    HYDROCHLORIC   ACID. 

A  number  of  chemical  tests  have  been  devised  for  the  detection 
of  hydrochloric  acid. 


.Q2  DIET   IN   DISEASE. 

Giinzberg's  Test  for  Free  Hydrochloric  Acid.— 

Phloroglucin 2 

Vanillin i 

Absolute  alcohol 30-     Mix. 

Two  or  three  drops  of  this  solution  are  placed  on  a  white  porce- 
lain dish  and  allowed  to  slowly  flow  in  contact  with  a  similar  quan- 
tity of  filtered  gastric  juice.  The  dish  is  very  slowly  and  gently 
heated  over  a  spirit  flame  or  Bunsen  burner,  and  if  hydrochloric  acid 
is  present,  a  faint  rose-red  hue  appears  at  the  line  of  contact,  which 
deepens  as  evaporation  continues  into  a  brilliant  cherry  red.  If  the 
acid  is  abundant,  minute  cherry-coloured  crystals  will  form.  If  the 
acid  is  feeble,  it  is  best  to  concentrate  the  stomach  filtrate  upon  a 
water  or  sand  bath  to  about  one  tenth  of  its  original  bulk. 

When  a  very  faint  trace  merely  of  the  free  acid  is  present  the 
appearance  of  the  colour  should  be  carefully  watched,  for  it  is  very 
evanescent. 

Gunzberg  showed  that  one  drop  of  the  normal  gastric  juice — i.  e., 
juice  containing  0.2  per  cent  of  free  hydrochloric  acid — when  diluted 
ten  times,  should  still  give  the  colour.  If  it  appears  when  the  dilu- 
tion is  carried  beyond  this  limit,  hyperacidity  is  present. 

This  is,  on  the  whole,  the  most  reliable  clinical  test  which  has  yet 
been  devised,  and  the  ease  and  quickness  of  its  application  for  diag- 
nostic purposes  has  much  to  recommend  it.  It  requires  no  special 
skill,  and  should  always  be  made,  to  test  the  progress  of  the  treat- 
ment, while  lavage  is  being  performed. 

The  Boas  Test  for  Hydrochloric  Acid. — The  Boas  test  is 
performed  in  a  similar  manner  to  the  Gunzberg  test,  but  the  colour 
produced  varies  from  rose  to  vermilion,  and  the  solution  is  made  as 
follows  : 

Sublimed  resorcin 5 

Sugar 3 

Dilute  alcohol 100.     Mix. 

Both  tests  are  only  of  value  from  a  positive  standpoint — i.  e.,  if 
the  colour  reaction  occurs,  free  hydrochloric  acid  is  surely  present. 
They  are,  however,  of  little  or  no  value  as  negative  tests,  for  the 
reason  that  if  peptones  or  certain  other  substances  are  present  in  the 
stomach  contents  the  reaction  may  be  entirely  obscured.  The  latter 
difficulty  is  met  by  application  of  the  calcium-carbonate  test,  which 
is  uninfluenced  by  other  substances  likely  to  be  associated  with  the 
gastric  juice,  with  the  single  exception  of  an  excess  of  acid  phos- 
phates. 

The  Calcium-carbonate  Test. — This  is  conducted  as  follows : 
A  sample  of  gastric  contents  is  heated  to  remove  fatty  acids,  and 
shaken  with  ether  to  remove  any  lactic  acid  present,  and  blue  litmus 
paper  is  dipped  in  the  fluid.     Another  blue  litmus  paper  is  dipped  in 


THE   ALIMENTARY   CANAL. 


493 


a  fresh  sample  of  the  gastric  contents  which  has  been  neutralised 
by  the  addition  of  dry  pure  CaCOj.  The  redness  of  the  first  paper 
when  compared  with  the  second  will  declare  the  presence  of  free 
hydrochloric  acid. 

A  strong  Giinzberg  reaction  usually  indicates  normal  reaction  or 
hyperacidity.  Its  absence  when  hydrochloric  acid  is  revealed  by 
the  CaCOj  test  indicates  subacidity.  If  the  latter  test  fails,  then  no 
free  acid  is  present. 

Acid  Salts. — If  the  litmus  dipped  into  the  gastric  juice  neu- 
tralised by  CaCOj  is  reddened,  the  presence  of  acid  salts  (phosphates) 
is  indicated. 

The  normal  gastric  free  hydrochloric  acid  maintains  a  remarkable 
uniformity  in  strength,  very  rarely  exceeding  0.2  per  cent. 

It  has  been  shown  by  Ewald  and  Leo  that  it  is  not  secreted  dur- 
ing fasting,  but  enters  the  stomach  as  soon  as  the  stimulus  of  food 
is  felt.  At  first  it  replaces  the  acids  from  lactates  and  phosphates, 
setting  these  acids  free  and  forming  chlorides  with  their  bases.  The 
hydrochloric  acid  also  unites  with  albuminoids.  For  these  reasons 
free  HCl  is  not  apparent  in  the  gastric  juice  until  the  combinations 
mentioned  have  been  all  saturated,  after  which  it  increases  in 
strength  to  the  normal  standard  of  0.15  to  0.2  per  cent.  If  alkalies 
are  ingested,  more  HCl  is  secreted;  but  if  acid  be  taken,  the  further 
secretion  of  HCl  is  checked,  so  that  the  average  strength  is  pre- 
served. 

These  conditions  explain  why  it  is  that  within  fifteen  minutes 
after  ingestion  of  an  Ewald  test  breakfast  lactic  acid  may  be  found 
in  the  stomach  contents,  while  free  HCl  may  not  appear  for  half  or 
three  fourths  of  an  hour. 

Lactic  acid  is  obtainable  for  an  hour,  or  until  the  full  strength  of 
free  HCl  secretion  is  reached.  If  a  heavy  meal  of  bread  and  meat 
and  vegetables  has  been  eaten,  the  lactic-acid  reaction  will  continue 
for  a  couple  of  hours,  but  free  HCl  may  not  be  demonstrated  for 
from  three  to  four  hours. 

This  is  an  observation  of  considerable  practical  importance ;  for  in 
the  early  stage  of  digestion,  the  acidity  being  low  and  due  only  to 
organic  acid,  the  ptyalin  digestion  of  starches  still  continues,  but  it 
must  cease  as  soon  as  any  appreciable  quantity  of  HCl  is  present. 

Free  hydrochloric  acid  checks  any  further  development  of  organic 
acids,  such  as  butyric,  acetic,  or  lactic.  The  Bacilli  acidi  lactici  fail 
to  act  in  its  presence,  and  other  bacilli,  like  those  of  typhoid  fever 
and  cholera,  are  destroyed  by  the  antiseptic  action  of  the  HCl. 

HYPERSECRETION. 

Hypersecretion  of  gastric  juice  is  determined  by  withdrawing  the 
contents  of  the  stomach  in  the  morning  after  lavage  the  previous 


.g^  DIET   IN   DISEASE. 

evening.  If  more  than  fifty  cubic  centimetres  are  obtained,  hyper- 
secretion may  be  said  to  exist  (Kinnicutt),  the  acid  nature  of  which 
is  to  be  decermin&d  by  the  Gunzberg  test  (page  492).  Suggestions 
for  the  diet  of  such  cases  are  given  on  page  500.  Gastric  atony  is 
determined  by  finding  in  the  morning  washing  of  the  stomach  un-" 
digested  particles  of  food  eaten  the  night  before. 

The  microscopic  examination  of  the  washing  will  exhibit  the 
bacteria,  sarcinae,  and  saccharomyces.  The  treatment  of  this  condi- 
tion is  given  under  Chronic  Gastric  Catarrh,  and  Dilatation  of  the 
Stomach,  page  511. 

TEST   FOR    PEPSIN. 

The  presence  of  pepsin  may  be  determined  by  digesting  either 
egg  albumen  or  blood  fibrin,  the  latter  being  preferred.  The  fibrin 
is  whipped  from  fresh  beef  blood  and  washed  in  water  until  it  be- 
comes white.  A  small  piece  is  placed  in  a  test  tube  with  fifteen  or 
twenty  cubic  centimetres  of  filtered  gastric  juice,  and  kept  at  a 
uniform  temperature  of  40°  C.  for  two  or  three  hours.  If  there  is 
but  little  normal  HCl  present,  a  few  drops  more  should  be  added. 
If  no  digestion  occurs  after  some  hours,  pepsin  is  absent  and  the 
fibrin  will  decompose.  Quantitative  or  comparative  tests  may  be 
made  by  using  definite  amounts  of  fibrin  and  gastric  juice,  and 
noting  the  time  required  for  complete  digestion. 

TEST  FOR  RENNET  FERMENT. 

The  presence  of  the  rennet  ferment  is  easily  demonstrated  by 
adding  a  few  cubic  centimetres  of  the  filtered  gastric  juice  to  a  half- 
teacupful  of  fresh  milk,  and  keeping  the  mixture  for  a  short  time  at 
40*^  C.  A  loose  coagulum  forms  with  a  limpid  yellowish  whey  if 
rennet  is  present. 

TEST   FOR    MOTOR    POWER   OF   THE   STOMACH. 

The  motor  power  of  the  stomach  is  demonstrated  in  various 
ways. 

Leube's  Method. — Leube's  method  is  to  empty  the  stomach 
after  the  ingestion  of  a  Leube's  test  dinner  (page  490),  or  Ewald's 
test  breakfast  (page  490).  If  the  stomach  is  empty  three  hours 
after  the  former  and  one  and  a  half  after  the  latter,  hypermotility  is 
present — i.  e.,  the  food  is  being  too  rapidly  hurried  into  the  duode- 
num. If  undigested  food  remains  six  or  seven  hours  after  eating 
the  Leube  test  dinner,  the  motility  is  impaired,  and  the  diet  must  be 
regulated  accordingly  (see  Chronic  Gastric  Catarrh,  page  505,  and 
Dilatation,  page  511). 

Ewald  and  Siever's  Method. — Another  method,  that  of  Ewald 
and  Siever's,  is  very  simple,  but  not  very  reliable.     Fifteen  grains  of 


THE  ALIMENTARY   CANAL. 


495 


salol  are  given  in  a  wafer  immediately  after  a  meal,  and  the  urine  is 
tested  for  salicyluric  acid,  which  is  derived  from  salicylic  acid  formed 
in  the  alkaline  intestine  as  one  of  the  products  of  dissociation  of 
salol.  Salol  escapes  being  acted  upon  by  the  gastric  juice,  and  the 
salicyluric  acid  appears  in  the  urine  half  an  hour  or  an  hour  after  it 
is  swallowed  if  hypermotility  be  present — otherwise,  not  for  several 
hours.  The  salicyluric  acid  is  readily  detected  by  the  violet  colour 
which  appears  in  the  urine  on  adding  a  drop  or  two  of  ferric-chloride 
solution.  The  chief  difificulty  in  the  performance  of  the  test  is  in 
getting  urine  when  wanted  without  catheterisation.  Frequent  cathe- 
terisation  merely  for  the  purposes  of  such  a  test  is  to  be  condemned, 
and  patients  cannot  usually  micturate  every  fifteen  minutes.  Brun- 
ner  and  Huber  prefer  to  make  the  test  dependent  upon  the  disap- 
pearance of  all  trace  of  salicyluric  acid  after  ingestion  of  one 
gramme  of  salol.  Normally  it  can  be  detected  for  only  twenty-four 
hours,  but  if  the  motor  power  of  the  stomach  is  impaired  it  may  be 
obtained  as  late  as  forty-eight  hours  after. 

Bourget  found  that  the  reaction  time  is  delayed  an  hour  or 
more  by  giving  a  dose  of  HCl  with  a  meat  meal,  whereas  it  is 
accelerated  by  a  less  acid  meal  of  which  fruits  and  vegetables  form 
a  part. 

Stewart,  in  referring  to  this  experiment,  points  out  that  hyper- 
acidity of  the  gastric  juice,  by  neutralising  the  duodenal  juices, 
might  retard  the  salol  reaction  without  the  existence  of  motor  in- 
sufficiency. 

Klemperer's  Method. — Klemperer  has  the  patient  swallow  one 
hundred  grammes  of  olive  oil  into  an  empty  stomach,  or  the  oil  may 
be  poured  in  through  a  stomach  tube.  It  is  left  for  two  hours,  and 
then  the  stomach  contents  are  washed  out.  The  oil  is  abstracted 
from  the  washing  with  ether,  and  the  ether  is  separated.  The  oil  is 
then  measured.  Between  seventy  and  eighty  grammes  of  oil  should 
pass  on  into  the  intestine  inside  of  two  hours,  but  if  it  has  not  done 
so  there  is  lack  of  motility. 

TEST   FOR   ABSORPTIVE   POWER  OF   THE   STOMACH. 

This  test,  as  devised  by  Penzoldt  and  Faber,  is  very  simple. 
Into  an  empty  stomach  are  taken  three  grains  of  potassium  iodide 
in  a  clean  gelatin  capsule,  with  a  wineglassful  of  water. 

The  saliva  is  collected  at  two-  or  three-minute  intervals  in  sepa- 
rate saucers,  and  with  normal  absorption  from  a  healthy  stomach 
iodine  may  be  detected  in  the  secretion  in  from  six  and  a  half  to 
fifteen  minutes,  but  in  gastric  catarrh  it  may  not  appear  for  several 
hours.  The  test  is  made  by  dipping  a  filter  paper,  previously  soaked 
in  starch  paste,  into  the  saliva,  and  adding  fuming  nitric  acid.  A 
blue  colour  appears  if  iodine  is  present.     This  test  is  not  very  reli- 

34 


496 


DIET   IN   DISEASE. 


able,  for  if  the  stomach  is  full  of  food  the  reaction  is  always  much 
retarded,  as  it  also  is  by  fever  and  in  most  diseases  of  the  stomach, 
notably  ulcer,  carcinoma,  and  dilatation. 

DIETETIC   TREATMENT   OF   DYSPEPSIA. 

The  foregoing  details  of  the  clinical  examination  of  the  digest- 
ive power  of  the  stomach  have  been  given  in  this  connection  as  a 
convenient  place  to  summarise  them.  It  is  not  intended  to  imply 
that  every  case  of  simple  dyspepsia  should  be  subjected  to  so  com- 
plex an  examination,  but,  on  the  other  hand,  there  are  many  persons 
afflicted  with  chronic  dyspepsia  who  waste  much  time,  energy,  and 
expense  in  taking  medicines  and  diet  "cures  "  which  are  entirely  un- 
adapted  to  their  particular  trouble  because  it  has  never  been 
thoroughly  investigated  by  the  only  means  which  in  really  serious 
cases  permit  of  an  accurate  diagnosis.  The  passage  of  a  stomach 
tube  two  or  three  times  is  all  that  is  necessary  for  the  patient  to 
submit  to  to  enable  such  a  diagnosis  to  be  made,  and  although  it  is 
never  an  agreeable  process,  it  is  far  better  than  to  prolong  indefi- 
nitely a  condition  of  great  discomfort,  and  one  which  in  time  may 
develop  into  much  more  serious  ills. 

The  dietetic  treatment  of  dyspepsia  is  so  complex  that  it  is  easier 
for  some  persons  to  be  put  upon  a  very  rigidly  restricted  diet  for  two 
or  three  weeks  than  to  have  to.  select  for  themselves  appropriate 
articles  at  each  meal. 

It  includes  the  study  of  all  classes  of  foods,  and  for  convenience 
they  may  be  grouped  into — 

A.  Foods  forbidden  in  all  cases. 

B.  Foods  occasionally  allowable. 

C.  Foods  which  are  desirable. 

A.  Foods  forbidden  in  all  Cases.— 

1.  Rich  soups,  gravies,  and  sauces. 

2.  Strong  condiments,  pickles. 

3.  Fresh  soft  bread  of  any  kind  (which  makes  a  tenacious  bolus), 
hot  breads,  pastry  of  all  kinds,  cakes,  griddle  cakes,  doughnuts, 
muffins. 

4.  Sweets,  tarts,  jam,  confectionery  and  candies  of  every  kind. 
Sugar  in  all  forms,  especially  in  coffee  and  tea  with  milk. 

5.  Raw  vegetables,  such  as  celery,  radishes,  coleslaw. 

6.  Heavy  starchy  vegetables — potatoes,  sweet  potatoes,  corn,  peas, 
beans,  eggplant,  cabbage,  cauliflower,  Brussels  sprouts,  turnips,  car- 
rots,  parsnips  (all  the  roots  and  tubers). 

7.  Fat  in  quantity,  all  fried  or  greasy  food. 

8.  Lobsters,  crabs,  shrimps,  salmon,  herring. 

9.  Dried,  smoked,  cured,  potted,  or  "devilled"  meats,  fish,  and 
pork  in  every  form. 


THE   ALIMENTARY   CANAL. 


497 


10.  Corned  beef,  duck,  goose,  wild  fowl,  rabbit.  Veal,  except  as 
broth. 

11.  Twice-cooked  meats,  hash  (unless  freshly  made,  without  pota- 
toes), stews,  ragoHts. 

12.  Cheese  of  all  kinds. 

13.  Very  acid  or  very  sweet  fruits,  nuts,  dried  fruits  in  general. 
All  skins  and  seeds  of  fruits. 

14.  Tea,  beer,  and  sour  wines. 

The  excessive  use  of  tobacco  in  any  form  should  be  forbidden. 

B.  Foods  Occasionally  Allowable. — There  are  foods  which 
may  be  allowed  to  some  patients  but  not  to  others,  and  many  of 
them  constitute  exceptions  to  the-  foregoing  general  rules.  Such- 
are: 

Vegetables. — Mealy,  well-baked  potatoes,  not  too  young  or  new, 
raw  tomatoes,  spinach,  thoroughly  boiled  onions,  very  young  tender 
fresh  peas,  very  young  Lima  beans,  string  beans,  asparagus,  stewed 
celery,  celery  plant  (sea-kale). 

Starchy  Foods. — Where  it  is  desirable  to  give  starchy  food  in  some 
form,  macaroni,  spaghetti,  or  rice  may  be  allowed,  or  one  of  the  pre- 
pared foods,  such  as  Carnrick's  or  Mellin's. 

Fats. — Bacon,  very  fat,  sliced  thin  and  well  broiled ;  cream,  good 
fresh  butter,  olive  oil. 

Eggs. — Many  patients  find  that -eggs  disagree  with  them  con- 
stantly. There  are  a  few  who  can  take  them  with  impunity  if  rightly 
cooked — that  is,  cooked  very  slowly  and  soft.  They  sometimes  agree 
better  when  not  given  with  other  food,  but  as  eggnog. 

As  a  rule,  sweet  fruits  disagree,  though  they  can  be  eaten  by  some 
patients. 

C.  Desirable  Foods  to  be  recommended  in  Ordinary  Cases 
are : 

Cereals. — Wheaten  bread,  porous  or  aerated,  stale  or  toasted ;  dry, 
unsweetened  rusk  or  Zwieback ;  soda  crackers.  (The  bread  from 
some  bakers  is  easier  of  digestion  than  that  from  others.)  Macaroni, 
sometimes  oatmeal,  but  without  sugar. 

Fats. — In  moderation  only ;  butter  to  be  very  thinly  spread  and 
well  rubbed  in.     Sometimes  a  thin  rasher  of  bacon. 

Vegetables. — Chiefly  as  purees,  thoroughly  cooked,  made  of  toma- 
toes, asparagus,  or  sometimes  potatoes  or  fresh  peas.  (Fresh  green 
vegetables  as  in  preceding  list.)     Lettuce. 

Fish. — Oysters,  fresh-boiled  or  broiled  fish  without  rich  sauces. 
They  may  be  eaten  with  a  little  fresh  butter  and  salt.  (Some  per- 
sons cannot  eat  fish  at  all.) 

Eggs. — In  any  form  if  they  are  found  to  agree  (except  hard- 
boiled  or  fried). 

Sweetbreads,  Meats. — Broiled  steak  or  chop,  tender  roast  beef  or 


g  DIET   IN   DISEASE. 

mutton,  chicken  (roasted  or  boiled),  boiled  capon,  roast  partridge, 
grouse,  woodcock,  plover,  prairie  chicken,  squab.  All  meats  should 
be  short-fibred  and  tender.  They  need  not  be  very  rare.  Grilling 
is  the  best  method  of  cooking  them. 

Fruit. — Baked  or  stewed  apples  or  prunes.  Occasionally  a  little 
fresh  fruit  in  season,  better  eaten  between  meals  to  prevent  constipa- 
tion.    Oranges,  peaches,  grape  fruit. 

Naturally,  in  bad  cases  the  diet  must  be  still  further  restricted, 
and  a  bread-and-milk  regimen  may  have  to  be  enforced  until  im- 
provement occurs. 

Beverages. — Tea  is  generally  injurious,  especially  if  drunk  with 
meals,  but  weak  tea  taken  clear  in  very  hot  water  is  sometimes 
beneficial  by  enabling  patients  to  imbibe  the  fluid  which  they  need. 
Strong  tea  is  astringent;  it  precipitates  pepsin  and  provokes  consti- 
pation. Coffee,  on  the  contrary,  favours  peristalsis,  and  is  mildly 
stimulating  to  the  nervous  system.  Drunk  with  milk  and  sugar  it 
often  excites  dyspepsia  and  increases  flatulency.  Taken  black  after 
dinner  it  is  an  adjunct  to  digestion.  If  it  produces  insomnia  or 
"  nervousness  "  it  should,  of  course,  be  discontinued.  Yeo  says  that 
both  tea  and  coffee  may  cause  dyspepsia  in  those  who  are  under 
mental  strain,  but  not  otherwise  in  the  same  individual.  Light 
China  teas  are  less  injurious  than  the  stronger  Indian  varieties.  Cof- 
fee contains  more  tannin  than  tea,  which  has  only  a  trace.  It  does 
not  itself  ferment,  but  the  milk  and  sugar  drunk  with  it  does. 

Cocoa  (not  chocolate,  which  is  too  sweet)  may  be  allowed.  An 
infusion  of  cocoa  nibs  often  agrees. 

Milk  and  Vichy  or  milk  and  Seltzer  may  be  drunk  as  a  beverage 
in  non-flatulent  cases. 

As  a  general  rule,  malt  liquors  and  beers  of  all  kinds  must  be 
forbidden,  although  Fagge  recommends  the  use  of  light,  still,  bitter 
ale  or  of  porter  in  some  cases;  but  he  says,  "Whatever  causes 
flushing  of  the  face  after  meals  is  bad."  Alcoholic  dyspepsia  is 
only  cured  by  entire  cessation  of  drinking.  This  the  patients  are 
unwilling  or  unable  to  accede  to  unless  very  strongly  influenced  or 
frightened  as  to  the  probable  outcome  of  continued  indiscretion. 
In  simple  atonic  dyspepsia  the  use  of  pure  wine,  or  weak  brandy,  or 
whisky  and  water  drunk  at  meals  may  prove  serviceable.  Some- 
times a  little  dry  wine,  claret,  or  hock  may  be  allowed  twice  a  day 
with  meals. 

Tobacco,  smoked  in  moderation,  in  the  form  of  mild  cigars  or  in 
pipes  (not  cigarettes),  promotes  digestion  by  slightly  stimulating  the 
nervous  system  and  increasing  peristalsis. 

Special  Systems  of  Treatment. — The  following  systems  of 
treating  dyspepsia  are  condensed  from  the  writings  of  several  of 
the  best-known  dietists: 


THE   ALIMENTARY   CANAL. 


499 


Dujardin-Beaumetz  divides  dyspepsia  into  three  classes,  and 
regulates  their  diet  accordingly,  as  follows: 

I.  Dyspepsia  with  abundant  gastric  juice.  Diet,  fresh  vegetables 
and  fruits,  farinaceous  food,  milk,  no  meat  or  wine. 

II.  Dyspepsia  with  deficient  gastric  juice.  Diet,  meat,  broths, 
milk,  peptonised  food,  weak  brandy  and  water.  No  vegetables  or 
saccharine  food. 

III.  Dyspepsia  with  sympathetic  affections,  especially  vertigo. 
Diet,  purely  vegetable  food. 

His  diet  of  vegetable  food  is  very  liberal,  and  includes  cereals 
as  well  as  fruits.  It  contains  such  articles  as  dry  bread  crust, 
toast;  farinaceous /i^r/if.y  made  of  one  of  the  following  materials  : 
Maize,  flour,  chestnut  meal,  oatmeal,  pearl  barley,  potatoes,  lentils, 
revalenta,  macaroni  (plain  or  buttered),  vermicelli ;  purees  of  fresh 
vegetables,  such  as  green  peas,  carrots,  turnips ;  the  vegetables 
of  julienne  soup;  salads,  spinach,  sorrel,  French  beans,  fruits, except 
grapes  cooked  as  compote,  lightly  cooked  eggs. 

Germain  See's  treatment  of  dyspepsia  is  exactly  the  reverse  of 
that  of  Dujardin-Beaumetz.    He  divides  dyspeptics  into  two  classes: 

I.  Those  who  have  hyperacidity  of  the  gastric  juice,  for  whom  he 
prescribes  a  nitrogenous  diet  with  sodium  bicarbonate  after  meals. 

II.  Those  having  diminished  acidity,  for  whom  he  prescribes  a 
purely  vegetable  regimen,  with  dilute  hydrochloric  acid  after  meals. 

He  directs  in  all  cases  to  wash  out  the  stomach  and  stimulate 
the  gastric  mucous  membrane,  for  which  he  orders  the  alkaline 
sodium  bicarbonate  in  a  tumblerful  of  Vichy  an  hour  and  a  half 
before  eating. 

Leube  graduates  dyspeptics  into  four  groups  according  to  the 
severity  of  their  symptoms.  The  diet  which  he  recommends  is  as 
follows,  commencing  with  the  severest  cases: 

I.  Broth  or  clear  soup,  Leube's  meat  extract,  milk,  eggs  (raw 
or  lightly  cooked),  carbonic-acid  water,  Apollinaris,  or  Seltzer, 

II.  Boiled  calves'  brains,  sweetbread,  breast  of  chicken  or  squab, 
bread  and  milk,  custard,  unsweetened  tapioca  pudding. 

III.  The  same  as  the  two  preceding,  with  the  addition  of  raw 
ham  \sic\  and  rump  steak.  The  latter  is  strongly  beaten,  scraped, 
and  roasted  quickly  before  a  hot  fire  with  a  little  fresh  butter. 

IV.  This  diet,  intended  for  the  mildest  cases  or  for  convales- 
cence, includes  milk,  rice,  spinach,  roast  chicken,  partridge,  venison, 
rare  beef,  veal,  macaroni,  fresh  green  vegetables,  salads,  fruit  com- 
potes, stewed  apples,  and  light  wines.  '•  He  sometimes  allows  fish, 
such  as  bass. 

General  Rules  for  Dyspeptics. — The  followirkg  general  rules 
are  applicable  to  all  cases  of  dyspepsia  and  indigestion  : 
I.  Eat  slowly,  masticate  thoroughly. 


-QQ  DIET   IN    DISEASE. 

2.  Drink  fluid  an  hour  before  or  two  or  three  hours  after  meals, 
rather  than  with  food. 

3.  Eat  at  regular  hours. 

4.  If  greatly  fatigued,  lie  down  and  rest  quietly  before  and  after, 
luncheon  and  dinner  or  supper. 

5.  Avoid  as  far  as  possible  taking  business  worries  or  profes- 
sional cares  to  the  table. 

6.  Take  systematic  exercise  in  the  open  air.  Bicycle  and  horse- 
back riding  are  the  best  forms. 

7.  On  rising,  cold  sponging  and  vigorous  friction  of  the  body  is 
advisable. 

8.  The  bowels  should  be  kept  open  by  laxative  foods  and  fluids 
rather  than  by  medicines. 

9.  Avoid  too  much  variety  at  any  one  meal.  Take  meats  and 
vegetables  at  separate  meals. 

RULES  FOR   SPECIAL   VARIETIES   OF   DYSPEPSIA. 

Dyspepsia  with  Excessive  Flatulency.— This  often  occurs 
in  nervous  women,  and  is  especially  annoying  at  night. 

Avoid  particularly  all  sweets  and  amylaceous  food.  No  fluid 
with  meals.  Drink  hot  water,  half  a  pint  before  meals,  and  again  two 
hours  after.  Do  not  eat  vegetables  and  meat  at  the  same  meal. 
Try  cream  instead  of  milk  in  coffee,  and  saccharin  instead  of  sugar. 
Avoid  tea  and  alcohol,  especially  malt  liquors  and  effervescing  water, 
with  meals. 

Dyspepsia  with  Hyperacidity. — The  diet  should  consist 
largely  of  rare  finely  minced  or  scraped  beef  (one  hundred  grammes, 
or  three  and  a  quarter  ounces,  is  ample),  with  two  slices  of  stale 
bread  or  toast,  or  a  few  crackers  with  a  little  butter  (thirty  grammes). 
Later  the  patient  may  partake  of  the  lighter  fresh  vegetables  and 
subacid  fruits.  Milk  may  be  useful.  Vegetables  should  be  thor- 
oughly cooked  and  mashed  or  made  into  purees.  Fruit  must  be 
stewed  or,  in  the  case  of  apples,  baked. 

A  six  weeks'  course  of  such  a  diet  faithfully  adhered  to  often 
results  in  cure. 

Dyspepsia  with  Excessive  Nervousness,  Irritative  Dys- 
pepsia.— Avoid  tea,  coffee,  much  alcohol,  tobacco,  stimulating  food 
of  all  sorts,  condiments  and  pickles,  and  do  not  overeat.  Eat  slowly. 
Avoid  eating  when  fatigued  or  worried.  Take  one  or  two  extra 
meals  a  day,  if  necessary,  especially  a  light  one  before  retiring,  to 
promote  sleep  (see  Insomnia). 

In  the  main,  vegetable  food  will  be  better  borne  than  proteids, 
unless  flatulency  is  annoying. 

Atonic  Dyspepsia,  Dyspepsia  with  Deficient  Gastric 
Juice. — Take  three  meals /^r  diem,  and  freshly  cooked  meat  should 


THE   ALIMENTARY  CANAL. 


50.1 


be  included  in  two  of  them.  Beef,  mutton,  and  poultry  are  recom- 
mended. Meat  broths  and  soups,  stale  bread,  toast,  or  crackers. 
All  meats  should  be  tender  and  simply  cooked. 

In  purely  atonic  dyspepsia,  with  loss  of  tone  in  the  muscular 
wall  of  the  stomach  and  sluggish  secretion,  a  diet  which  is  too  bland 
and  tasteless  fails  to  stimulate  the  stomach  sufficiently,  and  it  is 
better  to  offer  a  reasonable  variety  and  a  moderate  use  of  condi- 
ments. 

Dyspepsia  in  the  Gouty. — Avoid  particularly  sugar  in  every 
form,  malt  liquors,  sweet  wines,  and  champagne  (see  Gout). 

Dyspepsia  with  Bulimia. — A  certain  class  of  dyspeptics  are 
always  abnormally  hungry,  for  hunger  is  a  general  sense,  due  to 
the  needs  of  the  tissues  rather  than  to  the  purely  local  condition  of 
the  stomach.  Suffering  from  indigestion,  they  fail  to  assimilate 
food  properly,  become  hungry  again  soon  after  meals,  and  do  not 
obtain  the  full  nutritive  value  of  what  they  do  eat.  They  therefore 
overeat  or  eat  between  meals,  and  do  not  give  the  stomach  sufficient 
time  for  rest.  They  must  be  taught  to  restrain  the  appetite  and  to 
stop  eating  short  of  satiety  to  prevent  overloading  the  stomach,  and 
a  sufficiently  long  period  should  intervene  between  meals  for  the 
thorough  digestion  of  the  food. 

Dyspepsia  with  Anaemia. — Anaemic  patients  require  abundant 
nitrogenous  food,  and  well-seasoned,  stimulating  meat  broths  are 
recommended.  Such  patients  may  take  an  extra  luncheon  or  two  be- 
tween the  regular  meals  and  before  retiring  (see  Anaemia,  page  460). 

DYSPEPSIA   IN   CHILDREN, 

Children  vomit  much  more  easily  than  adults  when  they  have 
taken  improper  food,  and  often  suffer  less  in  consequence,  although, 
if  such  food  is  retained,  they  may  have  a  gastric  fever  with  a  greater 
rise  of  temperature  and,  perhaps,  more  alarming  symptoms  than 
occur  later  in  life. 

When  vomiting  occurs  in  infants  the  stomach  should  be  rested  by 
omitting  the  next  feeding,  and  for  the  second  feeding  the  milk 
should  be  diluted  and  reduced  in  amount.  If  vomiting  persists,  a 
little  bicarbonate  of  soda  or  one  or  two  tablespoonfuls  of  lime  water 
should  be  added.  Other  substances,  such  as  gelatin  or  one  of  the 
prepared  infant  foods,  may  be  added  temporarily  to  dilute  the  milk 
and  prevent  the  formation  of  laf*ge  curds  in  the  stomach.  In  ob- 
stinate cases  it  may  be  well  to  change  the  diet  completely  and  give 
up  milk  for  a  few  days.  In  place  of  it  a  mixture  may  be  used  con- 
sisting of  one  part  of  cream  and  two  parts  each  of  whey  and  boiled 
(not  boiling)  water. 

An  overfed  infant  vomits  soon  after  nursing  or  taking  the  bottle, 
and  the  stools  contain  milk  curds.    When  an  infant  receives  too  little 


tQ2  I>IET    IN    DISEASE. 

food,  "the  bottle  is  emptied  quickly  and  ravenously  ;  the  child  cries 
when  it  is  taken  away,  sucks  violently  at  its  fingers,  and  cries  before 
the  next  feeding  is  due  "  (Holt). 

Older  children  should  not  be  allowed  to  eat  between  meals,  and 
must  be  forbidden  the  premature  use  of  coffee,  tea,  spices,  coarse 
vegetables  (cabbage,  turnips,  etc.),  and  unlimited  ice  water,  fruits, 
and  sweets  (see  Diet  for  Infants  and  Diet  for  Children). 

Acute  Gastric  Catarrh. 
Causation. — Acute  gastric  catarrh  is  commonly  due  to  dietetic 
errors,   although    it    is   also    excited    in    other   ways.     The   dietetic 
causes  are: 

1.  Food  taken  in  too  large  quantity. 

2.  Food  too  hastily  swallowed  or  "bolted." 

3.  Food  in  itself  irritant  or  too  highly  seasoned  with  sauces,  con- 
diments, fats,  etc. 

4.  Food  which  has  undergone  decomposition,  such  as  "  high  " 
game  or  fish,  overripe  cheese,  sour  milk,  or  improperly  canned 
vegetables. 

5.  Alcohol  habitually  consumed  in  excess  and  in  concentrated 
form,  or  a  combination  of  drinking  beer  and  wine  or  liquor,  or 
drinking  beer  in  excess  with  improper  food. 

It  may  be  caused  by  corrosive  poisons.  Many  individuals  appear 
to  have  special  weakness  or  irritability  of  the  stomach,  so  that  at- 
tacks of  gastric  catarrh  are  excited  in  them  by  conditions  which 
would  prove  insufficient  in  others. 

Excessive  consumption  of  food  beyond  the  wants  of  the  system 
and  out  of  proportion  to  the  gastric  juice  is  often  an  exciting  cause 
of  gastric  catarrh,  especially  in  children.  This  food  need  not  in 
itself  be  indigestible.  Such  cases  may  result,  for  example,  from 
eating  large  quantities  of  meat  hash  or  of  ice  cream.  Favourable 
circumstances  are  also  present  in  anaemia,  nervous  exhaustion,  con- 
valescence from  protracted  illness,  and  in  fevers,  in  all  of  which 
conditions  the  gastric  juice,  and  especially  its  hydrochloric  acid, 
is  apt  to  be  diminished  in  amount  or  temporarily  absent.  In  these 
cases  digestion  is  retarded  far  beyond  the  ordinary  limits,  and  the 
retained  food  decomposes  by  abnormal  fermentation,  thus  becom- 
ing both  a  mechanical  and  a  chemical  irritant  to  the  mucous  mem- 
brane. 

Symptoms. — The  chief  symptoms  dependent  upon  the  local  in- 
flammation of  the  stomach  are  severe  vomiting,  nausea,  pain,  weak- 
ness, and  fever. 

Dietetic  Treatment. — Acute  inflammation  of  any  structure  is 
best  treated  by  rest,  and  the  stomach  forms  no  exception.  Hence 
total   abstinence  from  food   and  great  reduction  in  the  quantity  of 


THE   ALIMENTARY   CANAL. 


503 


fluid  imbibed  is  often  curative  after  an  interval  of  twenty-four  or 
thirty-six  hours.  The  irritation  is  maintained  by  ill-advised  at- 
tempts to  give  food  at  frequent  intervals  with  the  object  of  support- 
ing the  strength.  The  attacks,  from  the  very  nature  of  their  causa- 
tion, often  occur  in  robust  people  who  can  well  afford  to  forego 
nourishment  for  a  few  hours  or  until  the  nausea  and  pain  cease.  In 
others  who  have  been  enfeebled  by  continued  illness  or  in  whom 
the  acute  attack  produces  alarming  prostration,  enemata  and  stimu- 
lants and  predigested  albuminous  food  must  be  given. 

The  vomiting  and  nausea  are  allayed  by  cracked  ice,  small  quan- 
tities of  iced  champagne,  carbonic-acid  water,  plain  soda  water,  cold 
lime  water  sipped  in  doses  of  a  tablespoonful  at  a  time  and  at  inter- 
vals of  fifteen  minutes..  Strong  black  coffee  is  also  serviceable. 
These  symptoms  may  also  be  relieved  by  hot  poultices  and  turpen- 
tine stupes,  or  spongiopiline  soaked  in  hot  water  and  sprinkled  with 
a  few  drops  of  laudanum  placed  over  the  epigastrium  (Fagge). 

The  thirst  should  not  be  met  by  large  draughts  of  water,  which 
only  distend  the  stomach  and  excite  vomiting.  It  may  be  relieved 
by  sucking  a  piece  of  sliced  lemon  or  by  placing  a  few  drops  of 
mineral  acid,  such  as  dilute  phosphoric  or  dilute  hydrochloric  acid, 
in  a  small  tumbler  of  cold  water  and  sipping  it  from  time  to  time. 
Thirst  may  be  lessened  in  some  cases  by  holding  water  in  the  mouth 
for  a  few  moments  without  swallowing  it,  for  a  certain  amount  of 
fluid  is  absorbed  directly  through  the  buccal  mucous  membrane.  If 
large  quantities  of  fluid  have  been  vomited,  a  simple  enema  of  salt 
and  water  (fifteen  giains  to  the  pint)  may  be  injected  into  the  rec- 
tum, where  it  is  soon  absorbed. 

When  nourishment  is  first  taken  by  the  mouth,  it  must  be  fluid 
and  carefully  prepared,  so  that  it  will  either  undergo  prompt  absorp- 
tion or  pass  into  the  duodenum  for  digestion.  It  must  be  admin- 
istered only  in  small  doses — half  an  ounce  or  an  ounce  at  a  time. 
Pancreatinised  milk,  or  cold  milk  diluted  with  an  equal  volume  of 
lime  water  or  soda  water  or  alkaline  Vichy,  milk  whey  flavoured  or 
added  to  beaten  white  of  egg,  beef  extracts,  peptone  solutions,  black 
coffee,  expressed  meat  juice,  and  beef  tea  properly  made,  are  all  rec- 
ommended. Most  broths  contain  too  much  fat  or  oil.  Milk  given 
alone  or  undiluted  soon  curdles  in  the  stomach,  and  is  promptly 
ejected  in  large  tough  coagulae.  Many  persons  either  actually  can- 
not digest  milk,  or  more  commonly  think  they  cannot,  and  avow  a 
violent  distaste  for  it,  declaring  that  it  leaves  a  perpetual  bad  taste 
in  the  mouth  and  causes  headache  and  nausea.  Their  experience 
is  usually  based  upon  the  use  of  undiluted  and  unprepared  milk,  and 
with  tact  and  perseverance  they  can  be  got  to  retain  and  digest 
prepared  milk  very  well  (see  Milk  Predigestion,  page  67).  Some 
patients  prefer  warm  milk  diluted  with  water  and  flavoured  with  a 


504  I5IET   IN   DISEASE. 

little  cinnamon,  a  taste  of  coffee  or  caramel,  or  thej'  may  take  barley 
water  and  rice  water. 

If  patients  cannot  drink  milk  they  may  be  allowed  mutton,  veal, 
or  chicken  broths  from  which  the  fat  has  been  removed. 

It  is  best  to  forbid  all  alcoholic  fluids,  even  champagne,  unless 
the  patient  is  so  exhausted  that  some  stimulation  becomes  necessary, 
in  which  case  brandy  diluted  with  soda  water  may  be  given  in  small 
quantities,  or  it  may  be  added  to  beef  tea  or  arrowroot  gruel.  It  is 
important  always  to  aid  the  recovery  of  the  digestive  organs  by  ab- 
solute bodily  and  mental  quiet. 

Convalescence. — In  convalescence  the  diet  must  be  very  slowly 
increased ;  otherwise  relapses  may  follow  very  easily.  After  some 
degree  of  improvement  has  been  reached,  the  gastric  mucus  accumu- 
lates with  more  butyric-acid  fermentation,  and  the  vomiting  and 
other  symptoms  return. 

At  first  but  one  article  at  a  time  should  be  added  to  the  fluid 
food,  gradually  replacing  it.  Broths  may  be  thickened  by  beaten  or 
dropped  eggs,  crumbled  toast,  or  scraped  beef  or  chicken.  Later 
plainly  cooked  meat,  such  as  broiled  tenderloin  steak,  chicken,  a  ten- 
der chop,  squab,  or  a  bit  of  broiled  fresh  fish  with  lemon  juice  may 
be  allowed  with  dry  toast  and  rice  pudding. 

It  is  well  to  give  dilute  hydrochloric  acid  (ten  to  fifteen  drops) 
with  five  grains  of  pepsin  after  each  meal.  When  the  illness  has 
been  very  severe  the  patient  must  be  cautioned  to  be  careful  in  eat- 
ing for  several  weeks  after  the  acute  symptoms  have  subsided  lest  a 
relapse  or  gastric  dilatation  occur.  Alcoholic  subjects  will  probably 
not  heed  this  warning,  but  it  should  be  given  none  the  less. 

ACUTE   GASTRIC   CATARRH.— GASTRIC   FEVER   IN   CHILDREN. 

Acute  gastric  catarrh  in  infants  is  oftenest  due  to  improper  feed- 
ing. It  is  also  excited,  or  rather  promoted,  by  teething  and  other 
reflex  irritations  which  interfere  with  the  normal  stomach  functions. 
There  is  an  acute  inflammation  of  the  gastric  mucous  membrane, 
accompanied  by  more  or  less  fever,  vomiting,  local  pain,  and  ano- 
rexia. This  affection  is  comparatively  rare  among  nurslings.  When 
it  does  occur  in  them,  the  mother's  milk  should  be  analysed,  and  any 
errors  in  her  own  mode  of  life,  diet,  etc.,  must  be  corrected.  If  the 
breast  milk  continues  to  disagree,  a  wet  nurse  must  be  procured,  and, 
failing  this,  the  child  must  be  weaned  if  the  disorder  continues. 

Children  just  weaned  acquire  the  disease  from  overfeeding  and 
from  improperly  prepared  food,  and  the  number  of  meals  must  be 
carefully  regulated  according  to  the  rules  for  infant  feeding. 

Older  children  who  are  allowed  to  come  to  table  develop  the  dis- 
ease from  eating  too  rich  or  stimulating  articles,  such  as  pickles, 
sauces,  spiced  dishes,  sweets,  pastry,  fried  food,  from  drinking  large 


THE   ALIMENTARY  CANAL.  505 

quantities  of  hot  or  very  cold  fluid,  from  eating  hurriedly  without 
proper  mastication,  or  from  gorging  themselves  with  enormous 
quantities  of  articles  of  which  they  are  particularly  fond,  such  as 
hash,  cakes,  etc. 

If  seen  early,  if  vomiting  has  not  already  occurred  and  the  stom- 
ach is  full,  it  should  be  emptied  by  an  emetic  dose  of  ipecac.  Other- 
wise, if  the  stomach  contents  have  passed  into  the  intestine,  the  irri- 
tating food  should  be  expelled  by  a  laxative,  such  as  calomel  or  grey 
powder.  No  food  should  be  allowed  for  some  hours,  for  it  will  keep 
up  the  hyperaemia.  Nothing  should  be  swallowed  but  a  few  sips  of 
water  or  a  teaspoonful  of  cool  lime  water  or  a  little  cracked  ice. 
After  ten  or  twelve  hours  of  complete  rest  the  stomach  may  tolerate 
one  or  two  teaspoonfuls  of  pancreatinised  milk  or  milk  diluted 
one  half  with  lime  water  or  Vichy.  If  this  is  not  retained,  it  is  bet- 
ter to  give  a  little  meat  juice  or  beef  broth.  The  next  day  mild 
farinaceous  food  may  be  allowed,  such  as  arrowroot  gruel,  corn- 
starch, or  farina.  Junket  also,  or  milk  toast,  may  be  retained.  It  is 
best  to  return  to  a  solid  diet  very  slowly  and  carefully,  and  such 
articles  as  rice  pudding,  scraped  beef,  the  breast  of  chicken,  or  the 
soft  part  of  oysters  may  be  given  for  a  day  or  two  longer  before  the 
regular  diet  is  resumed. 

For  some  time  after  an  attack  it  may  be  best  to  reduce  the  num- 
ber of  meals /<?r  diem — a  child  who  hais  been  taking  five  should  take 
but  four,  or  one  who  has  had  four  should  take  but  three. 

Chronic  Gastric  Catarrh. — Chronic  Gastritis. 

Causation. — Chronic  gastric  catarrh  may  be  the  outcome  of 
such  errors  in  diet  as  have  been  described  as  causative  of  the  acute 
form.  It  commonly  results,  however,  from  alcoholic  excess.  It 
also  accompanies  diseases  in  which  the  hepatic,  and  consequently  the 
portal  circulation  is  obstructed,  producing  engorgement  of  the  ves- 
sels of  the  gastric  mucous  membrane.  It  may  complicate  pulmonary 
and  cardiac  diseases  which  cause  obstruction  to  the  venous  circula- 
tion.    It  is  caused  by  the  severer  forms  of  stomach  diseases. 

Patholog^ical  Physiology. — Besides  congestion  of  the  blood 
vessels,  which  interferes  with  the  maintenance  of  proper  secretion 
and  with  absorption,  the  glands  of  the  stomach  furnish  a  hypersecre- 
tion of  tenacious,  ropy,  alkaline  mucus,  which  clings  to  the  mucous 
coat  and  prevents  the  food  from  exciting  the  secretion  of  the  gastric 
juice,  and  it  neutralises  and  prevents  the  latter  from  reaching  the 
food.  The  food  therefore  is  retained  for  hours  in  an  alkaline  medi- 
um, where  it  undergoes  maceration  and  fermentation,  which  is  par- 
ticularly liable  to  develop  large  volumes  of  carbonic-acid  and  marsh 
gas,  which  are  periodically  belched  up  with  such  force  as  to  carry  out 
the  acrid  fluid,  and  even  particles  of  disintegrated  food,  producing  a 


5o6 


DIET   IN   DISEASE. 


bitter  and  nauseous  taste  in  the  mouth.  The  symptom  of  heartburn 
is  due  to  the  eructation  of  organic  acids.  The  appetite  is  not  always 
lost.  It  may  even  be  excessive,  and  it  is  usually  capricious.  Thirst 
is  often  a  prominent  symptom.  Vomiting  occurs  at  intervals,  espe- 
cially on  rising  in  the  morning,  after  the  gastric  mucus,  mingled  with 
the  saliva  swallowed,  has  accumulated  during  the  night. 

Dietetic  Treatment. — If  any  improvement  is  to  be  hoped  for 
in  the  condition  of  a  patient  with  chronic  gastritis  it  is  absolutely 
necessary  to  secure  the  intelligent  co-operation  of  the  patient  him- 
self by  strict  obedience  to  rules  which  must  be  made  very  specific 
and  distinct.  Many  patients  will  be  found  to  have  so  little  will 
power  that,  with  the  best  intentions,  when  they  sit  at  the  table  with 
others  whose  good  health  enables  them  to  partake  of  all  the  luxuries 
of  the  season  they  are  utterly  unable  to  resist  temptation. 

The  patient  with  gastric  catarrh  should,  as  far  as  possible,  be  kept 
from  mental  strain  and  worry  or  business  responsibilities,  and  espe- 
cially from  brooding  over  his  symptoms.  A  person  suffering  from 
chronic  gastritis  often  seems  to  have  but  a  small  amount  of  nervous 
energy  to  expend,  and  if  too  much  is  diverted  in  other  channels,  but 
little  is  left  for  the  processes  of  digestion,  and  gland  secretion  is 
altered  or  withheld.  It  is  a  matter  of  every-day  experience  with  such 
persons  that  when  free  from  all  concern  and  anxiety  their  digestion 
promptly  improves  and  they  can  often  eat  quite  indigestible  food, 
whereas  much  plainer  food  wholly  disagrees  with  them  while  under 
mental  strain.  It  is  highly  important  for  them  that  meals  should  be 
taken  with  regularity  and  that  abundant  time  should  be  allowed  for 
mastication.  Regular  habits,  outdoor  exercise,  and  daily  sponge 
bathing  in  cold  water,  followed  by  active  friction  of  the  skin,  are  to 
be  recommended.  In  forbidding  certain  classes  of  food,  it  is  often 
observed  that  the  patient  has  discovered  that  some  one  apparently 
•indigestible  material  can  be  eaten  with  impunity,  and  there  may  be 
no  harm  in  allowing  this  to  be  continued  in  mild  cases.  Sometimes 
merely  eliminating  from  the  diet  such  obviously  indigestible  foods 
as  pies,  griddle  cakes,  pickles,  fried  foods,  rich  cheese,  and  an  excess 
of  ice  cream  will  produce  marked  improvement,  but  it  is  often  neces- 
sary to  enforce  a  very  strict  regimen. 

Milk  Diet. — Severe  cases,  especially  those  complicating  Bright's 
or  cardiac  disease,  demand  rigorous  restriction  of  the  diet,  and  it 
may  become  necessary  to  give  milk  exclusively  for  two  or  three 
weeks.  From  two  to  two  and  a  half  or  three  quarts  of  fresh  milk 
are  required  for  this  diet  in  the  twenty-four  hours,  the  amount  de- 
pending upon  the  size  and  weight  of  the  patient  and  his  ability  to 
take  exercise.  The  latter,  however,  must  be  reduced  to  a  great  ex- 
tent while  the  milk  diet  is  in  force.  The  milk  may  be  given  either 
hot  or  cold,  but  hot  milk  is  best.     It  should  be  diluted  with  soda 


THE   ALIMENTARY   CANAL. 


507 


water  or  an  alkali,  such  as  sodium  bicarbonate  or  magnesia,  and  salt 
should  be  added.  Very  bad  cases  with  extensive  atrophy  and  abun- 
dant mucous  secretion  may  require  pancreatinised  milk  and  beef 
preparations. 

In  some  cases,  especially  those  due  to  chronic  alcoholism,  there 
is  annoying  thirst,  which  is  relieved  by  diluting  the  milk  with  equal 
parts  of  Vichy  or  Apollinaris  water.  The  fluid  has  the  additional 
advantage  of  increasing  the  elimination  of  waste  from  the  system 
through  the  kidneys. 

To  most  patients  who  are  ill  enough  to  require  a  fluid  or  an  ex- 
clusive milk  diet,  it  is  preferable  to  give  food  frequently,  at  the  rate 
of  four  ounces  of  the  above  mixture  once  in  two  hours,  until  the 
condition  of  the  stomach  improves,  when  the  dilution  of  the  milk  is 
to  be  reduced,  given  in  larger  quantity  (six  to  eight  ounces),  and 
the  intervals  may  be  prolonged  to  three  hours.  When  much  gastric 
irritation  or  nausea  exists,  the  milk,  if  at  all  rich  in  cream,  should  be 
skimmed,  as  fat  is  not  well  tolerated.  Buttermilk  is  used  quite  ex- 
tensively in  Germany  and  somewhat  in  this  country  for  the  treat- 
ment of  gastric  catarrh.  It  may  be  taken  undiluted.  To  some 
persons  the  taste  is  more  agreeable  than  that  of  ordinary  milk. 
The  casein  of  the  buttermilk  is  already  coagulated  and  exists  in  a 
condition  of  fine  subdivision,  so  that  it  does  not  form  large  clots  in 
the  stomach.  Patients  usually  tire  sooner  of  buttermilk  than  of 
plain  milk.  Milk,  no  matter  how  given,  is  apt  to  produce  consti- 
pation. 

When  patients  insist  that  milk  always  disagrees  with  them  this  is 
often  found  to  be  on  account  of  their  not  having  understood  its 
preparation  or  the  methods  by  which  it  may  be  prevented  from  form- 
ing tough  coagulae  in  the  stomach,  and  it  is  worth  while  to  explain 
this  fact  to  them,  and  secure  their  consent  to  give  a  fair  trial  to 
some  of  the  numerous  means  which  may  be  employed  for  improving 
the  digestibility  of  this  invaluable  food  (see  page  64).  If  there  is 
much  dilatation  of  the  stomach,  milk  is  usually  contraindicated. 

Other  Diet. — Should  it  prove  impossible  for  the  patient  to  digest 
enough  milk  to  support  strength,  his  diet  must  be  supplemented 
with  other  articles  of  food,  such  as  scraped  meat  or  peptoniStd  meat. 
As  a  rule,  the  food  should  be  either  fluid  or  almost  entirely  solid; 
drinking  considerable  fluid  with  solid  food,  dilutes  the  feeble  gastric 
juice  too  much  for  proper  digestion.  No  broth  or  soup  should  be 
allowed  with  meals.  Alcohol  should  in  general  be  forbidden,  and 
tea,  coffee,  or  cocoa  are  to  be  taken  only  in  moderation,  much  di- 
luted, and  without  milk  and  sugar.  Occasionally  light  wine,  such  as 
hock  and  Moselle,  may  be  given,  but  efi'ervescing  wines  are  forbid- 
den.    Fluids  should  not  be  taken  too  cold. 

Oysters  may  be  allowed  either  raw,  broiled,  or  panned.     Butter 


5o8 


DIET   IN   DISEASE. 


may  be  allowed  very  sparingly,  and  cream  sometimes,  but  in  gen- 
eral fats  and  oils  should  be  avoided  as  well  as  all  fat  meats,  pork, 
sausages,  and  solid  food  cooked  in  grease.  Rich  gravies  and  sauces 
of  every  kind  must  be  strenuously  forbidden,  and  all  solid  food 
must  be  thoroughly  masticated.  Many  persons,  especially  those 
who  have  an  excessive  secretion  of  hydrochloric  acid,  live  best  on  a 
diet  of  lean  roast  beef,  rare  steak,  or  white  meat  of  chicken,  eaten 
with  stale  white  bread  or  dry  toast  and  very  little  butter.  This 
diet  can  be  taken  for  some  time  before  serious  objection  is  made  to 
its  monotony. 

One  occasionally  meets  with  persons  in  whom  the  digestion  of 
salt  and  smoked  meats  seems  to  be  more  easily  accomplished  than 
that  of  fresh  meat.  The  explanation  offered  by  Niemeyer  is  that 
these  preparations  are  less  likely  to  decompose  and  form  abnormal 
fermentation  products  in  the  stomach.  Dried  smoked  beef,  cut  in 
thin  slices  and  eaten  almost  or  quite  raw,  is  palatable  and  easily 
digested.  Some  dyspeptics  can  also  digest  lean  boiled  ham,  lean 
smoked  bacon,  and  salt  fish,  such  as  shredded  codfish,  thoroughly 
cooked,  better  than  they  can  fresh  meat.  Leube  allows  caviare, 
smoked  ham,  and  boiled  lean  veal.  Tough  meat  and  flesh  of  young 
animals  recently  killed,  such  as  "  bob  "  veal,  must  not  be  eaten. 

Fish  and  soft-cooked  eggs  disagree  with  some  persons,  but  others 
can  digest  them  without  difficulty. 

Saccharine  and  farinaceous  foods  are  to  be  avoided.  Sooner  or 
later  they  are  almost  certain  to  undergo  lactic  and  butyric  acid 
fermentation  in  the  stomach  with  the  production  of  much  eructated 
flatus  and  "sourness."  When  improvement  is  established,  the  pa- 
tient may  gradually  be  allowed  a  little  carefully  prepared  starchy 
food,  but  still  no  sweets  of  any  kind.  A  single  lump  of  sugar  in  a 
cup  of  cafe  au  lait  drunk  at  breakfast  can  produce  an  acute  dyspep- 
sia, lasting  all  day.  The  varieties  of  starchy  foods  which  may  be 
first  eaten  are  those  which  have  been  thoroughly  subjected  to  the 
heat  of  baking  or  long  boiling.  Such  are:  Dry  bread  thoroughly 
toasted,  bread  crust,  plain  crackers.  Zwieback,  gruels  or  meat  soups 
thickened  with  arrowroot,  thoroughly  cooked  sago,  or  ground  rice, 
vermicelli,  and  macaroni  well  boiled.  The  purest  carefully  baked 
wheat  bread  from  hard  white  wheat  flour  agrees  better  than  the 
coarser  varieties  of  brown  bread,  whole-meal  breads,  etc. 

Many  persons  who  take  an  intelligent  but  not  hypochondriacal 
interest  in  their  digestion  find  by  repeated  trial  that  the  bread  of  a 
certain  baker  agrees  with  them,  while  that  of  another  does  not, 
although  its  nutritive  value  for  normal  stomachs  may  be  the  same 
in  both  cases. 

Potatoes  are  apt  to  produce  flatulency  with  sour  eructations,  and 
when  this  is  the  case  they  must  be  forbidden.     If  roasted  and  very 


THE   ALIMENTARY   CANAL. 


509 


mealy  they  may  be  sometimes  allowed.  Among  vegetables  those 
which  are  especially  forbidden  are  cabbage  and  cauliflower,  the  leg- 
umes, and  corn.  A  little  fruit  may  be  allowed  between  meals,  such 
as  cooked  apples,  either  baked  or  stewed,  or  stewed  prunes,  if  not 
too  sweet. 

Especially  forbidden  are  pastry,  sweets  of  all  sorts,  sweet  pud- 
dings and  cakes,  griddle  cakes,  hot  breads,  pickles,  fried  foods,  and 
strong  condiments. 

In  all  cases  of  chronic  gastric  catarrh  it  is  important  to  reduce 
the  bulk  of  food  taken  so  as  to  diminish  the  liability  of  its  remaining 
in  the  stomach  undigested.  Food  which  is  so  selected  and  prepared 
as  to  diminish  the  work  of  the  stomach  should  be  given  only  at  long 
intervals  in  order  that  the  digestion  of  one  meal  may  be  thoroughly 
accomplished  before  the  next  is  eaten.  It  is  well  to  order  at  least 
six-hour  intervals  between  the  meals,  and  they  should  not  be  eaten 
too  soon  after  exercise. 

Convalescence. — As  the  patient  improves,  the  dietary  may  be 
somewhat  enlarged,  and  thoroughly  cooked  fresh  vegetables,  such  as 
spinach,  celery,  asparagus,  onions,  and  fresh  young  peas,  may  be 
added. 

Fresh  ripe  fruit  will  be  found  serviceable  in  curing  constipation, 
which  almost  invariably  follows  as  a  result  of  concentrated  diet.  In 
many  cases  this  trouble  must  be  counteracted  by  the  daily  morning 
use  of  some  aperient,  and  a  half  tumblerful  of  hot  Hunyadi  water, 
or  of  Friedrichshall  bitter  water,  or  a  drachm  of  Carlsbad  salts  in  a 
tumbler  of  hot  water,  should  be  taken  each  morning  before  any  food 
is  swallowed.  The  salts  are  further  serviceable  by  diminishing  hy- 
peraemia  of  the  stomach  and  hepatic  engorgement.  Much  benefit  is 
derived  from  drinking  a  glass  of  hot  water  or  a  glass  of  hot  Vichy 
from  half  to  three  quarters  of  an  hour  before  each  meal,  the  object 
being  to  separate  the  layer  of  thick  ropy  mucus  which  overlies  the 
orifices  of  the  gastric  tubules.  Much  of  the  advantage  to  patients 
with  chronic  gastric  catarrh  received  from  a  course  of  treatment  at 
Carlsbad  and  similar  spas  is  due  to  the  action  of  sulphate  of  soda  and 
other  alkalies  in  removing  mucus  from  the  stomach  and  cleansing 
the  membrane  beneath,  rather  than  to  any  specific  virtue  in  the  salts 
themselves. 

Hydrochloric  Acid. — The  value  of  hydrochloric  acid  given  to 
aid  digestion  consists  quite  as  much  in  its  power  to  promote  the  con- 
version of  pepsinogen  into  active  pepsin  as  to  act  directly  upon  the 
food.  The  latter  can  be  accomplished  very  well  by  artificial  diges- 
tion outside  of  the  body.  If  therefore  there  is  complete  atrophy  of 
the  gastric  tubules  in  chronic  gastric  catarrh  of  long  standing,  the 
giving  of  the  acid  fails  to  excite  secretion  from  tubules  permanently 
destroyed,  and  Boas  declares  that  the  acid  combines  so  readily  with 


CIO  ^lE'T    ^N   DISEASE. 

the  salts  and  albuminoids  of  the  food  that  it  is  not  practicable  to 
give  enough  of  it  to  have  any  free  acid  remaining,  and  he  only  rec- 
ommends it  for  those  cases  where  the  function  of  the  gastric  tubules, 
as  shown  by  testing  the  digestive  power  of  a  sample  of  the  stomach 
juice,  is  not  wholly  abolished.  He  admits  its  usefulness  as  an  anti- 
fermentative.  This  view  is  not  generally  held,  however,  and,  as  a 
matter  of  practical  experience,  the  majority  of  these  cases  are  im- 
proved by  taking  dilute  hydrochloric  acid  with  any  solid  animal  food 
which  is  allowed  them  which  is  otherwise  found  to  cause  discomfort. 
It  is  best  to  give  the  acid  not  immediately  with  the  food,  but  half  an 
hour  later,  and  twenty  minims  may  be  prescribed  in  one  dose,  or  two 
or  three  doses  of  ten  or  fifteen  minims  may  be  given  at  intervals  of 
half  an  hour.  It  may  be  prescribed  alone  in  half  an  ounce  of  water, 
or  mixed  with  a  little  glycerin  in  a  claret  glass  full  of  water,  and  it 
should  be  swallowed  through  a  glass  tube  to  save  the  teeth  from 
injury. 

Exercise,  Massage,  Lavage,  etc. — Exercise  should  be  rec- 
ommended, but  so  regulated  as  not  to  interfere  with  digestion.  It 
should  be  postponed  until  digestion  has  been  in  progress  for  at  least 
an  hour  or  two,  and,  when  the  patient's  strength  admits  of  it,  gentle 
horseback  or  bicycle  riding  and  moderate  rowing  is  beneficial. 

Massage  of  the  stomach,  performed  two  hours  after  meals,  is  of 
service,  and  lavage  is  of  great  value  when  pyrosis  and  gastric  dis- 
tress occur  so  soon  after  eating  as  to  indicate  active  malfermentation. 

Daily  morning  douching  of  the  stomach  to  remove  mucus  and 
muco-pus  in  those  in  whom  a  dyspeptic  tendency  exists  will  serve 
to  prevent  the  advent  of  chronic  catarrhal  gastritis  (D.  D.  Stewart). 
This  process,  which  is  fully  described  in  connection  with  the  treat- 
ment of  Dilatation  of  the  Stomach  (page  513),  is  now  much  less  in 
vogue  than  formerly  for  simple  gastric  catarrh. 

Saline  laxatives  and  appropriate  tonics,  such  as  strychnine  and 
arsenic,  are  indicated  in  addition  to  the  dietetic  measures  above 
described. 

Electricity  is  of  service  only  when  one  pole  of  the  battery  is  intro- 
duced into  the  stomach  by  Einhorn's  method  (page  517). 

In  obstinate  cases  change  of  scene  and  occupation  may  do  much 
good,  and  a  sea  voyage  is  sometimes  to  be  suggested. 

CHRONIC   GASTRIC   CATARRH    IN   CHILDREN. 

Children  with  chronic  gastric  catarrh  should  always  eat  their  prin- 
cipal meal  in  the  middle  of  the  day,  and  take  only  a  light  supper. 

When  of  nervous  temperament,  they  are  apt  to  bolt  their  food 
without  proper  mastication.  At  the  age,  too,  when  their  deciduous 
teeth  are  being  replaced  they  may  from  time  to  time  have  difficulty  in 
eating  solid  food.     This  matter  should  be  inquired  into,  and  if  neces- 


THE   ALIMENTARY  CANAL. 


5" 


•  sary  all  such  food  must  be  minced  before  it  is  given  to  the  child. 
Children  accustomed  to  luxury  usually  overeat,  and  suffer  jn  conse- 
quence. Their  supervision  at  table  is  often  left  to  ignorant  or  care- 
less servants,  who  should  be  cautioned,  and  better  heed  will  be  taken 
if  the  instruction  is  given  by  the  physician  rather  than  by  an  indul- 
gent mother. 

In  young  children  gastric  lavage  is  easily  performed,  and  it  may 
be  quite  beneficial,  but  older  children  are  apt  to  struggle  and  resist 
it.  The  tube  may  be  passed  as  in  gavage  (see  Gavage),  and  direc- 
tions for  lavage  are  also  given  on  page  513.  For  this  purpose  it  is 
well  to  use  only  water  which  has  been  previously  sterilised  by  boiling. 

Dilatation  of  the  Stomach. — Gastrectasia. 

Causation. — Dilatation  of  the  stomach  may  result  from  stricture 
of  its  pyloric  end,  or  from  chronic  gastric  catarrh,  in  which  case  it 
is  accompanied  by  the  secretion  of  much  tenacious  mucus.  The 
stricture  may  be  due  to  a  carcinomatous  growth,  to  hypertrophied 
mucous  membrane  caused  by  chronic  gastritis,  or  to  contracture 
following  gastric  ulcer. 

Gastric  dilatation  is  also  produced  by  loss  of  tone  or  paresis  of 
the  muscular  coat,  by  destruction  of  the  muscular  coat  due  to  ulcer- 
ation, and  by  lack  of  proper  nervous  or  nutritive  supply,  such  as 
results  from  debilitating  illness,  like  typhoid  fever,  tuberculosis,  or 
general  nervous  prostration.  Less  often  it  is  caused  by  abuses  of 
diet,  especially  those  which  give  rise  to  much  gas  by  excessive  use 
of  effervescing  beverages,  etc.  The  varieties  due  to  gastritis,  de- 
bility, and  dietetic  errors  are  most  amenable  to  treatment. 

Pathological  Physiology. — The  food  is  improperly  digested, 
owing  to  want  of  gastric  juice  and  of  peristalsis  or  to  admixture  with 
quantities  of  mucus.  It  therefore  lingers  in  the  stomach  beyond  the 
usual  time,  ferments,  interferes  with  thorough  digestion  of  the  next 
meal,  and  renders  the  chyme  unfit  for  the  intestine.  Food  will  often 
lie  undigested  in  a  dilated  stomach  all  night,  and  be  vomited  with 
accumulated  mucus  in  the  morning.  The  undigested  food  accumu- 
lates, and  by  its  weight  drags  down  the  stomach  and  favours  further 
dilatation  by  stagnation  and  development  of  gases.  The  motor 
function  of  the  stomach  is  almost  completely  suspended,  and  the 
organ  must  therefore  be  taxed  as  little  as  possible. 

Dietetic  Treatment. — For  these  reasons  it  is  necessary  to  limit 
the  quantity  of  solid,  and  especially  of  fluid  nourishment.  Nothing 
but  the  simplest  articles  of  diet  should  be  allowed.  All  food  should 
be  given  in  a  concentrated  and  readily  assimilable  form,  so  that  it 
will  either  be  absorbed  directly  from  the  stomach  wall  or  pass 
promptly  into  the  duodenum. 

In  bad  cases  food  should  be  predigested  as  much  as  possible,  al- 
35 


qj2  DIET   IN   DISEASE. 

though  many  of  the  predigested  foods  are  open  to  the  objection  that 
they  are  much  diluted  in  the  process,  and  are  therefore  less  service- 
able. The  more  concentrated  varieties  should  be  chosen.  Ewald 
recommends  the  employment  of  peptonised  condensed  milk,  which  is 
very  nutritious  and  of  an  agreeable  flavour.  It  should  be  condensed 
without  addition  of  the  usual  excess  of  cane  sugar,  which  will  surely 
ferment  in  the  stomach. 

The  patients  are  often  thirsty,  and,  in  fact,  the  original  dilatation 
may  have  been  caused  by  excessive  imbibition,  but  the  amount  of 
fluid  drunk  with  meals  must  be  restricted  to  four  or  six  ounces,  or  in 
bad  cases  no  fluid  at  all  should  be  allowed  at  mealtimes.  If  the 
thirst  is  considerable,  a  tumblerful  of  hot  water  may  be  taken  a  half 
hour  before  meals,  to  be  absorbed  or  pass  into  the  intestines  before 
the  food  enters  the  stomach.  Water  is  more  quickly  absorbed  hot 
than  cold.  In  bad  cases  thirst  may  be  relieved  by  water  enemata, 
but  they  are  rarely  necessary. 

The  proper  diet  for  gastric  dilatation  is  the  same  as  that  recom- 
mended for  chronic  gastritis,  except  that  it  is  even  more  concen- 
trated and  smaller  in  bulk,  and  farinaceous  food  is  almost  wholly 
forbidden. 

At  first  only  animal  food  should  be  given,  such  as  scraped  beef  or 
apiece  of.  broiled  chicken,  with  perhaps  a  very  little  dry  toast  or 
toasted  cracker.  If  vomiting  is  a  persistent  symptom,  Petrequin  ad- 
vises the  patient  to  drink  milk  very  slowly,  taking  crushed  ice  with 
each  mouthful.  Later,  after  from  two  or  three  to  six  weeks,  if  im- 
provement has  resulted,  more  latitude  is  permissible,  and  the  food 
advised  is  lean  meat  free  from  coarse  fibres;  fresh  vegetables, young 
peas,  asparagus,  tomatoes,  tender  and  well-cooked  purees,  dry  bread, 
haricot,  lentils,  lettuce  or  cress  with  vinegar,  simple  starches,  such 
as  sago,  macaroni,  rice,  tapioca,  and  vermicelli,  boiled  or  broiled 
oysters  or  fish,  soft-cooked  eggs,  orange  juice,  stewed  or  baked 
apples  without  sugar,  stewed  pears.  Some  patients  may  drink  a 
tumblerful  of  boiled  milk  between  meals,  but,  as  a  rule,  it  is  best  to 
take  nothing.  Some  dietists  recommend  a  perfectly  dry  diet,  omit- 
ting all  fluids,  as  thick  soups,  and  order  three  meals  a  day  at 
long  intervals.  In  mild  cases,  coffee  and  tea  without  sugar  are  al- 
lowed. 

To  be  avoided  are  most  forms  of  starchy  food,  and  sugar,  pota- 
toes, old  peas,  beans,  corn.  Fruit  consists  largely  of  water  in  pro- 
portion to  its  nutritive  value,  and  its  vegetable  acids  are  apt  to 
disagree.  It  must  therefore  be  eaten  sparingly.  Fats,  butter,  and 
oils  are  not  digested  in  the  stomach.  Thirst-exciting  foods,  as  salt 
fish,  must  not  be  taken,  nor  beer,  effervescing  mineral  waters,  red 
wine,  thin  soups,  milk,  water,  tea,  coffee,  diluted  or  light  alcoholic 
beverages. . 


THE   ALIMENTARY   CANAL. 


513 


In  r.ll  cases  too  long  continuance  of  a  very  rigid  diet  is  liable  to 
cause  the  patient  or  the  stomach  itself  to  rebel.  The  patient  should 
be  weighed  once  a  week.  The  stools  must  be  examined  and  the 
general  nutrition  carefully  considered.  If  weight  is  rapidly  lost,  the 
food,  whatever  it  may  be,  is  not  being  assimilated,  and  it  should  be 
changed.  It  may  become  necessary  to  disregard  the  rules  for  fluid 
and  put  the  patient  for  a  time  upon  a  diet  of  prepared  milk. 

Aids  to  Dietetic  Treatment. — Other  means  of  treatment 
which  are  really  adjuncts  to  dietetic  measures  should  be  recom- 
mended. Such  are  lavage,  massage,  and  electricity,  which  will  be 
considered  below.  Mucus,  especially  that  which  is  accumulated 
overnight,  may  be  washed  out  of  the  stomach  by  sipping  a  cup  of 
very  hot  water  or  taking  alkaline  mineral  water,  or  a  pint  of  water 
with  ten  grains  of  bicarbonate  of  soda  or  boric  acid,  on  rising. 

It  is  often  desirable  for  the  patient  to  lie  down  for  an  hour  and  a 
half  after  eating,  and  he  should  especially  avoid  mental  and  bodily 
fatigue,  which  tend  to  divert  both  nerve  energy  and  the  blood  from 
the  functions  of  digestion. 

Hydrochloric  acid  and  pepsin  mixtures  with  the  nitrogenous  diet 
are  serviceable. 

Lavag^e. — In  cases  of  either  dilatation  or  catarrh  of  the  stomach 
which  fail  to  improve  on  restricted  diet  and  other  methods  of  treat- 
ment lavage  or  stomach  washing  becomes  necessary.  This  is  an 
entirely  safe  procedure,  and  one  to  which  patients  become  readily 
accustomed,  provided  sufficient  tact  and  care  is  employed  when  the 
method  is  first  applied.  It  was  first  practised  by  Kussmaul  in  1867. 
The  operation  met  with  so  much  success  that  it  has  since  that  time 
been  generally  adopted,  and  it  is  perfectly  easy  to  perform  with  a 
little  experience  and  care.  It  should  be  attempted  in  all  serious  cases 
in  which  other  methods  to  relieve  the  patient  have  been  already  tried 
and  have  failed.  It  is  almost  indispensable  in  those  cases  in  which 
the  atony  of  a  greatly  distended  stomach  wall  prevents  the  food 
from  being  expelled  into  the  intestine,  causing  constant  accumula^ 
tion  and  fermentation,  or  in  cases  in  which  decomposing  food  passes 
into  the  duodenum,  exciting  intestinal  dyspepsia,  meteorism,  and 
diarrhoea. 

As  many  as  sixteen  varieties  of  bacteria  have  been  obtained  from 
the  washings  of  a  dilated  stomach  in  which  food  had  been  stag- 
nating. 

The  advantages  of  lavage  are  twofold ;  it  not  only  removes  irri- 
tating and  fermenting  material  from  the  stomach,  and  the  ropy,, 
tenacious  mucus  which  it  contains,  and  allays  vomiting,  but  the 
water  itself  applied  to  the  mucous  membrane  cleanses  it  and  stimu- 
lates the  gastric  glands  to  normal  secretion  and  the  stomach  wall  to 
contraction.     It  also  promotes  more  regular  action  of  the  bowels. 


cj.  DIET   IN   DISEASE. 

The  relief  from  the  sensations  of  weight,  oppression,  discomfort, 
and  nausea  which  is  promptly  experienced  after  lavage  is  usually 
immediate  and  lasts  for  several  hours.  It  is  so  great  that  patients 
not  infrequently  learn  to  pass  the  oesophageal  catheter  themselves, 
and,  holding  a  pitcher  of  warm  water  in  one  hand  and  a  funnel  in 
the  other,  they  wash  and  siphon  out  their  own  stomachs  with  ease. 
Usually  it  is  sufficient  to  wash  the  stomach  once  a  day.  In  extreme 
cases  it  may  be  necessary  to  perform  the  operation  twice  a  day,  but 
when  improvement  is  once  established,  washing  may  be  limited  to 
every  other  day  or  may  be  employed  occasionally,  according  to  need, 
but  it  should  be  continued  for  several  weeks  after  the  subsidence  of 
all  symptoms.  As  a  result  of  this  treatment,  the  stomach  may  di- 
minish in  size,  and  the  food  is  always  better  digested  and  more  com- 
pletely absorbed,  while  nutrition  and  assimilation  are  correspond- 
ingly improved. 

The  best  time  for  digestion  of  the  principal  meal  of  the  day  is 
within  an  hour  after  each  lavage,  when  the  stomach  is  empty  and 
thoroughly  cleansed,  and  the  meal  can  often  be  assimilated  com- 
pletely. If  decided  repugnance  to  food  exists,  the  tube  may  be  used 
for  forced  feeding,  and  peptones  and  predigested  milk  may  be 
poured  in  before  it  is  withdrawn  from  the  stomach,  although,  as  a 
rule,  it  is  best  that  too  much  fluid  food  should  not  be  given. 

In  performing  the  operation  of  lavage  it  is  better  to  use  the 
siphon  than  the  stomach  plimp.  The  ordinary  tubes  sold  with 
stomach  pumps  are  far  too  stiff  to  introduce  frequently  into  the 
stomach  even  after  they  have  been  soaked  in  hot  water,  and  a  me- 
dium-sized oesophageal  tube  should  be  selected,  about  one  third  of  an 
inch  in  diameter,  having  two  or  three  large  smooth  eyes  or  "velvet" 
fenestra  and  made  of  good,  smooth  red  rubber  which  is  sufficiently 
flexible  without  being  so  easily  bent  as  to  allow  the  tube  to  double 
upon  itself  in  its  passage.  This  tube  should  be  fully  fifteen  inches 
long,  and  it  is  attached  to  a  length  of  three  feet  of  common  rubber 
tubing  by  means  of  a  small  glass  tube ;  the  other  extremity  of  the 
rubber  tubing  is  fastened  to  a  funnel  through  which  warm  water  is 
poured  into  the  stomach,  A  glass  funnel  is  preferred,  which  makes 
it  easier  to  examine  the  washings  as  they  return.  The  patient  is 
cautioned  to  keep  the  head  straight  forward  and  thrown  back  and 
not  to  bite  the  operator's  finger,  and  the  tube  is  gently  pushed  over 
the  dorsum  of  the  tongue  down  over  the  posterior  pharyngeal  wall 
into  the  oesophagus.  The  insertion  of  the  tube  will  be  facilitated  by 
oiling  it  slightly  with  a  little  olive  oil,  butter,  white  vaseline,  or  glyc- 
erin, but  white  of  egg  or  milk  are  less  likely  to  nauseate. 

If  there  is  any  difficulty  in  introducing  the  tube,  its  downward 
passage  may  be  aided  by  passing  the  forefinger  to  the  back  of  the 
pharynx.     If  the  patient,  who  either  sits  or  stands,  is  instructed  to 


THE.  ALIMENTARY   CANAL.  515 

make  an  effort  at  swallowing  while  the  tube  is  being  inserted  it 
will  descend  much  easier,  and  pains  should  be  taken  to  explain  the 
process  and  reassure  him,  for  nervousness  and  struggling  may  excite 
spasms  of  the  laryngeal  muscles  and  make  it  difficult  or  impossible 
to  pass  the  tube.  On  reaching  the  cardiac  end  of  the  stomach,  the 
tube  is  occasionally  stopped  for  a  moment,  but  the  patient  should 
be  instructed  to  try  and  swallow,  and  with  gentle  pressure  the  ori- 
fice soon  relaxes  and  the  tube  enters  the  stomach.  Or  a  little  water 
poured  into  the  tube  may  cause  the  cardia  to  relax.  The  funnel  is 
raised  above  the  patient's  head,  but  before  pouring  in  much  fluid  it 
should  be  ascertained  that  he  is  able  to  breathe  comfortably  and 
quietly  when  the  tube  is  momentarily  compressed.  He  should  be 
reassured  that  he  will  not  choke.  Accidents  have  occasionally  hap- 
pened from  passing  small  tubes  down  into  the  larynx,  and  I  have 
known  of  one  fatal  case  in  which  a  nasal  tube  was  thus  passed  and 
milk  was  poured  into  the  lungs.  A  case  has  been  reported  in  which 
beef  tea  was  poured  into  the  lungs  in  this  manner,  but  the  patient 
recovered  and  the  beef  tea  was  coughed  up  or  absorbed.  There  is 
very  little  danger  of  introducing  an  oesophageal  tube  of  the  or- 
dinary size  in  the  wrong  direction,  for  any  attempt  to  push  it  into 
the  pharynx  will  be  met  by  obstruction  and  spasmodic  coughing. 
If  the  stomach  is  full  when  the  tube  is  first  passed,  some  of  the 
contents  may  be  immediately  siphoned  out  by  lowering  the  funnel 
below  the  stomach  level  and  holding  it  over  a  foot  tub  or  pail.  If 
necessary,  water  can  be  poured  in  gently  to  the  extent  of  a  quart, 
or  until  the  patient  complains  of  uncomfortable  fulness  in  the 
stomach.  Care  should  be  exercised  not  to  admit  air  bubbles.  The 
tube  and  funnel  are  then  inverted  over  a  foot  tub  or  wash  basin 
and  the  contents  of  the  stomach  are  quickly  siphoned  out.  This 
operation  may  be  repeated  a  number  of  times  until  all  the  food  and 
mucus  have  been  removed  and  the  washings  return  quite  clear  and 
neutral  in  reaction. 

The  quantity  of  water  used  in  the  washing  should  be  measured 
so  that  it  all  may  be  siphoned  out  again,  as  it  is  undesirable  to 
leave  any  fluid  behind. 

When  the  tube  is  introduced  for  the  first  few  times  it  may  excite 
efforts  at  vomiting,  but  it  is  not  necessary  to  remove  it,  for  the 
patient  can  usually  regurgitate  the  long,  stringy  mucus  alongside 
of  it.  Salivation  is  often  produced  in  the  first  few  trials.  After  one 
or  two  attempts  patients  will  learn  to  swallow  the  tube  themselves 
with  very  little  assistance  and  cease  to  gag  upon  its  introduction. 
If  there  is  hyperaesthesia  of  the  pharynx  the  pharyngeal  wall  may 
be  touched  with  a  2-  or  4-per-cent  cocaine  solution  just  before  the 
introduction  of  the  tube,  or  several  large  doses  of  bromide  of  potas- 
sium may  be  administered  during  the  previous  twenty-four  hours. 


5i6 


DIET   IN   DISEASE. 


If  nausea  occurs  when  the  tube  first  reaches  the  cardia  it  is 
usually  overcome  by  pouring  in  a  little  fluid.  The  success  of  the 
operation  at  the  first  trial  depends  largely  upon  the  skill  of  the 
physician  and  the  degree  to  which  he  has  obtained  the  confidence 
of  his  patient,  and  has  been  able  to  overcome  any  nervous  feeling 
in  regard  to  a  process  which  is  at  best  highly  disagreeable.  After 
the  sufferer  from  gastric  dilatation  has  experienced  the  relief  which 
lavage  of  the  stomach  can  give,  he  usually  requires  no  urging  to 
allow  the  process  to  be  repeated.  In  withdrawing  the  tube  it  should 
be  compressed  in  order  to  avoid  having  any  of  its  contents  trickle 
into  the  larynx. 

The  fluid  used  for  washing  the  stomach  may  be  either  cool,  warm, 
or  quite  hot  water.  Warm  water  is  best,  but  it  is  well  to  sterilise  it 
by  previous  boiling.  If  much  mucus  is  present  or  much  acidity, 
sodium  bicarbonate  may  be  added  in  the  proportion  of  two  or  three 
per  cent  (15  grains  to  the  pint),  or  a  similar  quantity  of  sodium 
borate  or  boric  acid,  a  one-half-per-cent  solution  of  salicylic  acid,  or 
a  i-per-cent  solution  of  sodium  salicylate.  Vichy  is  occasionally 
used. 

The  best  time  for  conducting  lavage  is  shortly  before  the  midday 
meal,  the  patient  having  had  a  very  light  breakfast,  and  it  should 
only  be  performed  when  the  stomach  is  believed  to  be  compara- 
tively empty.  If  the  tube  is  introduced  before  breakfast,  having 
had  nothing  to  eat  for  a  number  of  hours,  patients  are  more  apt  to  be 
disagreeably  affected,  especially  if  the  washing  be  long  continued, 
and  I  have  occasionally  seen  them  become  faint  under  these  circum- 
stances. It  is  better,  therefore,  that  a  light  breakfast  of  bread  and 
milk,  pancreatinised  milk,  or  of  a  scraped-beef  sandwich  and  a  cup 
of  black  coffee  should  be  taken  ;  three  hours  later  the  stomach  is 
to  be  washed.  There  are  exceptional  cases  in  which  the  patient  is 
so  distressed  by  the  effort  to  pass  the  tube  or  by  the  operation  of 
rinsing  the  stomach  itself  that  it  has  to  be  abandoned.  Lavage 
must  be  avoided  in  cases  complicated  by  much  prostration,  feeble 
heart  action,  aneurism,  haematemesis,  or  haemoptysis. 

Accessory  measures  which  are  to  be  used  in  connection  with 
lavage  and  careful  regulation  of  diet  are  massage  and  medicinal 
treatment  which  consists  largely  of  the  administration  of  tonics, 
especially  strychnine,  with  the  object  of  increasing  the  muscular 
action  of  the  stomach.  This  remedy  may  be  given  hypodermically 
if  necessary. 

Massage. — Gastric  massage  should  be  performed  about  two 
and  a  half  or  three  hours  after  each  meal  for  ten  minutes.  The 
patient  must  lie  upon  his  back,  with  knees  drawn  up  and  muscles 
relaxed.  The  movements,  stroking  and  kneading,  must  be  always 
made  over  the  stomach  in  the  direction  of  the  pylorus,  the  object 


THE   ALIMENTARY  CANAL. 


517 


being  to  facilitate  emptying  the  stomach  through  that  opening,  and 
to  stimulate  peristalsis.  If  not  too  weak,  the  patient  may  be  taught 
to  perform  these  movements  himself.  This  treatment  is  often  of 
considerable  aid  in  mixing  the  food  and  gastric  juice  and  in  pro- 
pelling the  food  into  the  intestine.     It  increases  peristalsis. 

Electricity. — Faradisation  of  the  stomach  is  believed  by  many 
to  increase  its  muscular  tone,  and  various  forms  of  electrodes  have 
been  devised  for  this  purpose.  It  is  probable  that  very  little,  if  any, 
electric  stimulation  reaches  the  stomach  when  currents  of  ordinary 
strength  are  applied  over  the  epigastrium,  although  Ewald  and 
Sievers  claim  that  it  does  in  some  cases.  This  is  especially  true  of 
faradism.  Canstatt  first  proposed  to  apply  the  current  directly 
within  the  stomach  wall,  and  methods  have  been  devised  by  Bardet, 
Einhorn,  and  others  to  serve  this  purpose. 

The  ingenious  electrode  invented  by  Einhorn,  of  New  York,  is 
easily  passed  into  the  stomach.  His  electrode  consists  of  a  hard- 
rubber  capsule  about  the  size  of  a  small  French  olive.  The  hollow 
capsule  has  numerous  perforations  and  within  it  is  a  small  metallic 
electrode.  The  capsule  is  fastened  to  a  fine  flexible  conducting 
wire,  which  is  attached  to  the  battery,  and  the  wire  is  protected  by  a 
minute  soft-rubber  tube  one-tenth  inch  in  diameter.  This  electrode 
is  readily  swallowed  by  placing  it  upon  the  dorsum  of  the  tongue  and 
then  drinking  water.  About  forty  centimetres  of  the  wire  should  be 
swallowed.  In  withdrawing  the  electrode  after  use  it  sometimes 
catches  at  the  cardiac  end  of  the  stomach,  but  if  the  patient  swal- 
lows a  little  water  it  slips  past.  When  this  electrode  is  in  the 
stomach,  which  has  been  previously  partially  filled  with  a  pint  or 
more  of  warm  water  or  saline  solution,  the  second  electrode,  broad 
and  flat,  is  placed  over  the  epigastrium  or  over  the  back  to  the 
left  of  the  seventh  dorsal  vertebra,  and  the  electric  current  is  care- 
fully turned  on. 

This  treatment  is  designed  especially  to  increase  the  muscular 
tone  of  the  stomach  in  atonic  dilatation  and  stimulate  peristalsis, 
but  it  also  serves  to  promote  secretion,  and  hence  it  doubly  aids 
digestion. 

The  electric  current  may  be  applied  daily,  immediately  after 
lavage,  for  ten  or  fifteen  minutes,  and  it  should  be  strong  enough 
to  induce  good  peristalsis.  With  due  care  there  is  no  fear  of  in- 
juring the  heart.  Even  patients  who  are  not  accustomed  to  lavage 
seldom  object  to  swallowing  the  electrode. 

A  minute  electric  light  attached  to  the  end  of  the  oesophageal 
tube,  the  wire  running  through  the  tube,  has  been  invented  by  the 
same  physician.  The  glass  bulb  of  the  light  is  protected  by  a  small 
hard-rubber  cage,  or  a  second  glass  bulb,  so  that  there  is  no  possible 
danger  of  its  breaking  inside  of  the  stomach,     A  light  of  a  half- 


5ig 


DIET   IN   DISEASE. 


candle  power  will  shine  outward  through  a  thin  abdominal  wall  with 
sufficient  brilliancy  to  enable  one  to  outline  very  distinctly  the  limits 
of  a  distended  stomach ;  in  fact,  I  have  obtained  enough  light  from 
this  instrument  to  be  able  to  read  ordinary  print  from  it  when  the 
patient  was  shut  in  a  darkened  room,  if  the  page  was  held  close  to 
the  abdominal  wall.  The  illumination,  however,  is  merely  a  diffuse 
glow,  and,  as  is  to  be  expected,  it  does  not  enable  the  contents  of 
the  stomach,  or  even  the  relative  thickness  of  its  wall,  to  be  always 
recognised. 

A  variety  of  medicinal  remedies  are  also  used  with  the  object  of 
preventing  fermentation  of  food  in  the  stomach  and  intestine  and 
for  artificially  aiding  digestion  by  these  organs.  Among  the  former 
are  to  be  mentioned  creosote  and  other  substances  allied  to  carbolic 
acid,  naphthaline,  salicylic  acid,  etc.  The  use  of  hydrochloric  acid 
and  pepsin  have  been  described  in  connection  with  chronic  gastric 
catarrh  (page  509). 

Vomiting.— Seasickness. — Vomiting  of  Pregnancy. 

Vomiting  occurs  as  a  symptom  of  so  many  diseases  and  functional 
derangements  that  it  will  be  advantageous  to  consider  collectively 
the  general  dietetic  means  for  its  relief.  The  details  of  treatment 
will  be  explained  under  the  headings  of  the  various  diseases  in  which 
vomiting  may  become  a  serious  or  prominent  symptom. 

Patholog^ical  Physiology. — Vomiting  as  far  as  it  is  related  to 
dietetics  may  be  caused  by:  i.  Excess  of  food.  2.  Foods  and 
drinks  improperly  combined  (as  crabs  and  milk,  beer  and  champagne, 
etc.).  3.  Fermenting  or  poisonous  food.  4.  Irritating  and  indigest- 
ible food,  including  that  which  is  improperly  cooked.  5.  Hastily 
eaten  food. 

In  hysterical  patients  and  in  very  neurotic  conditions  of  the  sys- 
tem, either  the  sight,  taste,  smell,  or  mental  suggestion  of  food  may 
excite  nausea  and  vomiting. 

Instances  of  the  influence  of  the  mind  over  stomach  digestion 
and  the  mechanism  of  vomiting  are  too  familiar  to  need  elabora- 
tion here.  Food  which  is  in  itself  nourishing  may  promptly 
nauseate  through  disgusting  association  or  environment.  For  ex- 
ample, a  party  of  early  California  settlers  while  crossing  the  conti- 
nent were  lost  during  a  severe  winter  in  the  Sierras.  When  nearly 
dead  of  starvation  some  friendly  Indians  took  compassion  and  fed 
them  upon  a  delicious  finely  ground  meal,  which  for  some  days  was 
their  staple  article  of  diet,  and  on  which  they  rapidly  gained  strength. 
Being  at  first  unable  to  understand  the  Indians,  the  emigrants  could 
not  learn  of  what  the  meal  was  composed.  When  at  length  they 
found  out  that  it  was  made  from  pounded  dried  grasshoppers  they 
became  so  nauseated  that  none  could  touch  the  food  again. 


THE   ALIMENTARY   CANAL. 


519 


Dietetic  Treatment. — The  first  principle  in  the  dietetic  treat- 
ment of  vomiting  from  any  cause  is  to  give  the  stomach  rest.  If  it 
has  been  overloaded  with  a  large  bulk  of  food,  or  with  indigestible 
material,  it  is  well  to  encourage  emesis,  and  distressing  retching  may 
be  overcome  by  taking  large  draughts  of  lukewarm  water.  A  quart 
or  two  will  rinse  out  the  stomach  and  allay  irritation  to  a  marked 
degree. 

Well-nourished  patients  when  serious  vomiting  first  occurs  should 
usually  refrain  from  taking  food  of  any  kind  for  from  ten  or  twelve 
to  even  twenty-four  hours.  Exceptions  to  this  rule  are  sometimes 
found  in  that  type  of  seasickness,  and  sometimes  in  the  vomiting  of 
pregnancy,  in  which,  as  soon  almost  as  the  stomach  is  emptied,  there 
is  a  desire  to  replenish  the  loss. 

In  any  case  in  which  the  gastric  irritation  is  persistent  it  is  ne- 
cessary to  give  fluid  food,  and  only  in  small  oft-repeated  doses,  pref- 
erably in  predigested  form.  The  food  is  best  given  cold,  as  a  rule, 
although  some  persons  can  relieve  nausea  by  sipping  very  hot 
water. 

A  teaspoonful  of  prepared  milk,  or  in  extreme  cases  but  a  few 
drops,  given  with  a  medicine  dropper  once  in  ten  or  fifteen  minutes, 
may  be  all  that  the  stomach  will  at  first  tolerate. 

The  following  is  a  list  of  dietetic  substances  which  are  commonly 
prescribed  for  the  relief  of  nausea  and  vomiting,  or  for  nourishment 
while  those  conditions  exist :  Cracked  ice,  milk,  pancreatinised  ;  milk 
with  sodium  bicarbonate  (ten  grains),  and  cerium  oxalate  (five 
grains);  milk  and  lime  water;  milk  and  Vichy,  soda,  Seltzer,  or 
carbonic-acid  water ;  whey ;  koumiss  and  matzoon ;  beef  extracts 
and  peptonoids,  such  as  Johnson's  Fluid  Beef  and  Carnrick's  Beef 
Peptonoids,  somatose,  Valentine's  or  Liebig's  meat  juice;  raw  meat 
pulp,  scraped;  strong  black  coffee;  sour  lemonade  or  lemonade  and 
Vichy;  clam  broth.  Dry  crackers,  dry  toast,  and  ginger  snaps  will 
sometimes  be  retained  in  seasickness,  or  a  cracker  buttered  and 
sprinkled  with  a  little  Cayenne  pepper;  brandy  and  soda;  iced  dry 
champagne;  iced  brandy  diluted  with  water,  soda  water,  or  Apol- 
linaris. 

Very  severe  and  protracted  cases  may  require  lavage,  or  nutrient 

enemata.     Vomiting  after  abdominal    surgical   operations   is   often 

controlled  by  lavage. 

SEASICKNESS. 

There  is  no  known  dietetic  treatment  of  seasickness  which  is  ap- 
plicable to  many  cases.  There  are  those  who  overeat  because  of  the 
tonic  of  the  bracing  sea  air.  The  idleness  and  lack  of  accustomed 
exercise,  and  perhaps  something  in  the  quality  of  the  air  itself,  ail 
contribute  to  make  them  bilious,  and  unloading  stomach  and  bowels 
thoroughly  once  for  all  suffices  to  cure  them  for  the  rest  of  the 


-,Q.  DIET   IN   DISEASE. 

voyage.  The  habit  of  indulging  in  late  "  farewell  suppers  "  is  nat- 
urally the  worst  preparation  possible  for  a  sea  voyage. 

Some  persons  at  sea  can  leave  the  table,  vomit  the  first  two  or 
three  courses  of  a  dinner,  return,  and  finish  the  meal  with  astonish- 
ing equanimity.  With  them  nausea  is  not  a  persistent  or  annoying 
symptom,  and  they  need  no  treatment.  Others  are  always  nauseated, 
but  fail  to  vomit,  and  consequently  grow  weak  from  lack  of  food. 
They  do  well  to  take  a  mild  emetic  at  first,  and  usually  a  tumblerful 
of  lukewarm  water  will  serve  to  empty  the  stomach  of  food  lying 
there  undigested  and  fermenting.  They  are  then  temporarily  re- 
lieved, and  can  assimilate  some  form  of  predigested  food. 

Still  others,  after  severe  experience  with  emesis,  strongly  crave 
and  can  actually  retain  and  digest,  in  defiance  of  all  dietetic  laws, 
substances  which  they  could  scarcely  eat  at  home.  Old  cheese,  nuts 
and  raisins,  sour  pickles,  canned  lobster,  and  similar  incongruities  of 
diet  are  indulged  in  without  a  qualm. 

There  is  a  class  of  persons  of  both  sexes,  though  the  greater 
number  are  women,  who  become  so  ill  at  sea  as  to  reach  a  serious 
condition  of  prostration.  These  patients  are  constantly  nauseated, 
not  alone  by  the  taste,  but  by  even  the  sight  and  odour  of  food. 
The  mere  idea  of  it,  as  the  suggestion  from  reading  an  elaborate 
menu,  will  nauseate.  It  is  often  difficult  for  such  patients  on  a 
crowded  steamer  to  obtain  the  proper  food  and  service,  and  it  is  well 
for  them  to  go  provided  with  certain  articles  which  are  most  useful. 
Chief  among  these  is  sterilised  milk.  This  is  now  easily  obtainable 
before  sailing,  and  there  is  no  difficulty  in  keeping  it  fresh  during 
the  length  of  an  ordinary  transatlantic  voyage.  It  may  be  peptonised 
at  the  time  it  is  needed,  or  diluted  with  equal  parts  of  Vichy  or  lime 
water,  or  taken  with  ten  grains  of  bicarbonate  of  soda  and  three 
grains  of  cerium  oxalate  to  the  tumblerful.  The  Swiss  milk,  con- 
densed without  sugar,  may  also  be  used.  Fresh  lemons  and  sour 
oranges  are  very  acceptable  to  many  patients,  the  former  particu- 
larly so  on  account  of  their  greater  acidity  and  special  power  to  quiet 
the  nausea  of  seasickness.  The  juice  of  one  or  two  lemons,  squeezed 
into  a  tumbler  of  iced  Vichy  or  ApoUinaris,  with  a  little  sugar  or  sac- 
charin, and  a  pinch  of  bicarbonate  of  sodium,  makes  a  most  refresh- 
ing and  soothing  beverage. 

Prepared  clam  broth,  like  milk,  can  also  be  taken  in  bottles,  and 
it  often  allays  nausea.     It  is  mildly  stimulating  and  nourishing. 

Other  drinks  which  are  recommended  besides  those  above  men- 
tioned are  weak  brandy  and  soda  or  Seltzer,  cold  champagne,  or 
sparkling  Moselle.  Too  much  ice  water  should  not  be  drunk,  but 
cracked  ice  may  be  sucked.  Strong  black  coffee  is  excellent.  If 
there  is  uncertainty  about  this  being  obtained  good  at  sea,  the  ex- 
tract of  coffee  may  be  carried,  which  can  be  drunk  diluted  in  hot 


THE  ALIMENTARY   CANAL. 


-321 


water.  Coffee  distinctly  allays  nausea,  besides  being  a  good  cardiac 
stimulant  and  diuretic. 

It  is  not  well  to  take  too  much  soup  or  broth  at  once,  for  if  there 
is  much  motion  the  weight  of  the  fluid,  tipping  about  in  the  stomach 
as  the  vessel  rolls  and  pitches,  may  easily  accentuate  the  nausea. 
In  some  cases  patients  may  retain  dry,  solid  food  better  than  liquids, 
and  they  should  try  soda  crackers.  Zwieback,  lemon  ginger  snaps,  and 
chipped  smoked  beef,  which  can  be  obtained  in  boxes  at  the  grocer's 
before  sailing.  In  extreme  cases  it  may  be  necessary  to  use  beef 
peptonoids  or  other  meat  preparations,  such  as  beef  meal,  given 
either  by  mouth  or  in  eneraata.  Preserved  dry  ginger  helps  some 
persons.     Lime-water  tablets  may  be  used. 

Epigastric  applications  of  hot-water  bags  or  mustard  pastes 
afford  relief.  It  is  very  important  to  keep  the  bowels  freely  open 
with  bitter  water  of  some  sort.  Rubinat  is  less  objectionable  in 
taste  than  others.  Seidlitz  powders  are  usually  well  retained,  and 
so  is  citrate  of  magnesia. 

VOMITING   OF   PREGNANCY. 

The  vomiting  of  pregnancy  usually  takes  the  form  of  simple 
"  morning  sickness."  This  may  not  appear  until  the  patient  arises 
in  the  morning,  when  she  feels  faint,  dizzy,  and  nauseated.  Such 
cases  are  benefited  by  remaining  in  bed  until  a  glass  of  milk,  or  a 
cup  of  warm  broth  with  a  biscuit,  or  a  cup  of  cocoa  or  coffee  and  a 
sandwich  has  been  taken  and  digested.  There  may  then  be  no  re- 
turn of  nausea  during  the  day,  but  the  diet  should  at  all  times  be 
simple,  especially  the  last  meal  of  the  day,  and  all  richly  cooked 
food,  pastry,  sweets,  sauces,  and  elaborate  "  made  dishes  "  should  be 
avoided.     Beyond  this  such  patients  may  need  no  further  treatment. 

In  other  women  the  nausea  is  more  persistent,  and  in  the  worst 
instances  the  symptom  is  very  difficult  to  control  by  any  therapeutic 
or  dietetic  measures. 

Such  cases  are  to  be  treated  on  the  lines  suggested  above  for  the 
cure  of  vomiting  in  general  and  for  severe  seasickness.  Nutrient 
enemata  should  be  early  resorted  to  if  there  is  any  sign  of  failing 
strength,  and  before  a  patient  is  allowed  to  die  of  inanition  artificial 
delivery  may  be  necessitated.  Such  extreme  cases  are  fortunately 
very  rare. 

The  treatment  of  other  forms  of  vomiting  will  be  considered 
under  the  headings  of  Alcoholism  (page  364),  Acute  Gastritis  (page 
502),  Chronic  Gastritis  (page  506),  and  Dilatation  of  the  Stomach 
page  511). 


-^2  diet  in  disease. 

Ulcer  of  the  Stomach. 

In  ulceration  of  the  mucous  membrane  of  the  stomach  there  is 
danger  of  irritation  of  the  abraded  surface  through  either  the 
chemical  or  mechanical  action  of  the  food.  Excessive  secretion  of 
gastric  juice  itself  is  believed  to  be  similarly  irritating.  In  serious 
cases  where  the  ulcer  is  extensive  or  where  it  is  deep  and  the  stom- 
ach wall  is  thinned,  there  is  liability  of  a  rupture  being  caused  by 
overdistention  or  an  undue  amount  of  peristaltic  action.  In  the 
normal  relaxed  condition  of  the  stomach  wall  the  mucous  membrane 
is  folded  into  rugae,  but  when  it  is  slightly  distended  the  surface  is 
smoothed  out,  and  a  greater  degree  of  stretching  may  rupture  an 
ulcer  which  is  on  the  point  of  perforation,  but  which  might  still 
heal  over  if  the  tension  were  not  too  great.  Further  danger  from 
the  presence  of  ulcer  of  the  stomach  lies  in  the  fact  that  small 
blood  vessels  may  be  occasionally  eroded,  giving  rise  to  profuse 
haemorrhage,  and  any  food  which  irritates  the  surface  of  the  ulcer 
increases  this  risk. 

Dietetic  Treatment. — For  these  reasons,  if  the  patient  is  seen 
soon  after  the  occurrence  of  gastric  haemorrhage,  it  is  necessary  to 
withhold  all  alimentation  from  the  mouth  and  nourish  the  patient 
exclusively  upon  nutrient  enemata.  This  treatment  permits  the 
stomach  to  remain  relaxed,  and  it  is  not  stimulated  to  peristalsis  or 
secretion  of  irritating  gastric  juice. 

In  addition  to  the  ordinary  nutrient  enemata  it  may  be  advis- 
able twice  a  day  to  give  rectal  injections  of  a  pint  of  salt  water, 
which  by  its  absorption  prevents  thirst  and  relieves  the  patient  of 
the  craving  for  swallowing  liquid,  which  might  result  in  exciting 
further  vomiting.  In  severe  cases,  if  the  irritability  of  the  stomach 
continues  or  the  haemorrhage  is  repeated  it  becomes  necessary  to 
continue  the  rectal  alimentation  for  many  days,  and  patients  may 
live  upon  it  comfortably  for  a  week  or,  in  some  cases,  much  longer. 

Lavage  has  been  employed  successfully  when  vomiting  and  pain 
in  the  stomach  were  uncontrollable.  One  usually  hesitates  in 
adopting  this  practice  on  account  of  a  fancied  danger  of  pushing 
the  oesophageal  tube  through  the  weakened  wall  of  the  stomach, 
and  I  have  known  of  one  case  which  resulted  fatally  from  this 
procedure,  where  the  stomach  wall,  however,  was  already  eroded 
through  both  the  mucous  and  muscular  layers,  and  perforation 
in  any  event  was  imminent.  When  the  stomach  wall  is  weakened 
the  mere  act  of  vomiting  itself  is  a  menace  of  rupture,  and  the 
operation  of  lavage  is  justifiable  if  carefully  performed.  There  is 
no  special  danger  to  be  apprehended  from  the  use  of  a  very  flexible 
tube  which  is  not  pushed  too  far  into  the  stomach,  as  the  ulcer  is 
usually  some  distance  from  the  cardiac  end,  and  food  can  sometimes 


THE  ALIMENTARY  CANAL. . 


523 


be  poured  into  the  stomach  through  the  tube  after  lavage  with 
alkaline  water,  when  it  may  be  retained  and  digested.  This  treat- 
ment should  only  be  resorted  to  in  cases  where  haemorrhage  has  not 
occurred  within  a  week,  and  in  which  other  efforts  to  control  pain 
and  irritation  of  the  stomach  have  been  faithfully  tried,  but  have 
failed. 

Debove  recommends  the  use  of  the  oesophageal  tube  for  gav- 
age  when  vomiting  is  persistent  and  nutrient  enemata  are  not  satis- 
factorily retained.  The  tube  should  be  passed  as  far  as,  but  not  neces- 
sarily into,  the  stomach,  and  fluid  food  is  poured  through  it.  The 
act  of  swallowing  is  thus  avoided,  and  emesis,  as  in  the  case  of  infan- 
tile dyspepsia,  is  less  likely  to  follow.  If  the  tube  proves  irritating 
its  use  must  not  be  insisted  upon. 

Generally  speaking,  however,  after  a  day  or  tv/o  of  complete 
rest  the  condition  of  the  stomach  will  admit  of  the  gradual  resump- 
tion of  mouth  feeding,  but  nourishment  must  be  given  exclusively 
in  liquid  and  predigested  form.  The  object  is  to  give  only  food 
which  will  tax  the  stomach  as  little  as  possible,  and  either  be 
promptly  absorbed  or  pass  quickly  into  the  duodenum. 

At  first  but  very  small  quantities,  not  exceeding  one  or  two  tea- 
spoonfuls,  should  be  offered  at  one  time,  and  the  effect  in  regard  to 
nausea  or  vomiting  must  be  carefully  observed.  Later,  from  four 
to  six  ounces  should  be  given  every  two  hours.  For  those  cases  of 
ulcer  of  the  stomach  in  which  patients  are  allowed  to  take  food  per 
OS,  a  milk  diet  will  usually  agree  the  best,  provided  precautions  are 
observed  against  the  formation  of  large  curds  in  the  stomach,  which 
are  exceedingly  irritating.  The  milk  should  be  given  in  any  form 
in  which  it  is  best  borne,  and  the  reader  is  referred  to  the  article 
upon  the  modes  of  preparing  milk  and  rendering  it  digestible  (page 
64).  If  it  is  tolerated,  the  dosage  may  be  increased  to  three  to 
four  ounces  every  two  hours.  Peptonised  milk  gruel  is  strongly 
recommended  by  Roberts.  Da  Costa  has  found  that  ice  cream  gave 
unexpected  relief  in  some  cases.  Some  patients  do  well  upon 
koumiss,  buttermilk,  or  matzoon.  Ewald  advocates  the  use  of  milk 
thickened  with  flour  of  various  kinds  to  prevent  the  formation  of 
large  coagulae.  The  predigested  starchy  infant  foods,  such  as  Nes- 
tl^'s,  Mellin's,  Imperial  Granum,  or  malted  milk  may  be  added,  but 
gruels  made  with  coarse  cereals  are  not  permissible. 

When  milk  preparations  fail,  it  is  unwise  to  persist  in  giving 
them,  and  teaspoonful  doses  of  beef  juice  should  be  substituted,  or 
peptonised  solutions  or  pancreatinised  meat  juice  may  be  tried. 
Other  patients  may  be  fed  upon  ^gg  albumen  beaten  and  sweetened 
or  prepared  with  sherry  wine,  or  the  yolk  of  an  egg  may  be  beaten 
in  an  ounce  of  boiling  water  and  added  to  a  tumbler  of  milk.  Less 
serious  cases  may  be  allowed   such  articles  as  Zwieback   or  stale 


-24.  DIET   IN   DISEASE. 

bread  crumbs  or  cracker  crumbs  soaked  in  milk  until  quite  soft. 
They  will  prevent  the  formation  of  large  coagulse  of  milk.  One  of 
the  various  malt  preparations  may  be  well  tolerated  and  prove 
nutritious.  Leube's  Soluble  Meat  is  a  German  preparation,  which 
relieves  the  stomach  of  all  necessary  work,  and  consequently  re- 
duces the  period  of  acid  secretion  in  the  stomach.  It  proves  very 
serviceable  in  the  dietetic  treatment  of  gastric  ulcer,  and  may  be 
given  alone  or  combined  with  milk  cr  salted  meat  broths  and  bread 
crumbs.  Leube  himself  prescribes  in  this  form  an  equivalent  of 
half  a  pound  of  beef  in  twenty-four  hours,  and  claims  good  success 
for  it.     Mosquera's  meat  jelly  may  be  employed. 

As  a  rule,  if  a  patient  thrives  upon  a  diet  of  milk  and  broths, 
it  is  best  to  let  well  enough  alone  for  three  or  four  weeks,  and  any 
increase  in  either  the  quantity  or  variety  of  the  diet  should  be  made 
with  extreme  caution.  If  improvement  follows,  as  indicated  by  the 
diminution  in  pain  and  the  absence  of  gastric  distress  after  eating, 
and  the  patient  gains  in  strength,  other  articles  may  be  carefully 
added  in  moderation  to  the  diet,  such  as  milk  toast,  sweetbread, 
eggs  (not  hard-boiled),  scraped  meat,  custard,  a  small  piece  of 
boiled  or  broiled  white  meat  of  chicken  or  mutton  or  fish,  chicken 
broths  thickened  with  arrowroot,  rice,  vermicelli,  clear  meat  broths 
or  thickened  soups  to  which  the  yolk  of  an  egg  has  been  added, 
or  crumbled  dry  toast  and  a  carefully  prepared  pur/e  of  potatoes  may 
be  prescribed.      Stewart  recommends    the  addition   of  malt  to  the 

A  few  easily  digestible  solid  foods  may  next  be  added  to  the 
menu,  such  as  tender  rare  roast  beef,  beefsteak,  tender  game,  like 
the  breast  of  partridge,  quail,  or  squab  in  season.  The  soft  part  of 
large  oysters  (raw  or  broiled),  boiled  fresh  fish,  such  as  bass,  sole,  or 
whiting,  rice  pudding,  bread  and  milk  pudding,  tapioca,  sago,  farina, 
and  cornstarch — are  all  articles  which  may  be  permitted  in  moder- 
ation. 

The  patient  should  be  informed  of  the  existing  condition  in  the 
stomach,  and  of  the  dangers  attending  any  serious  departure  from 
the  rules  of  diet  carefully  laid  down,  and  it  should  be  explained 
that  for  several  months  after  the  acute  symptoms  of  gastric  ulcer 
have  subsided  the  greatest  care  must  be  observed  not  to  overload 
or  overwork  the  stomach,  and  to  refrain  from  eating  food  such  as 
coarse  bread  or  groats,  or  vegetables  having  tough  outside  cover- 
ings, like  peas,  corn,  and  beans,  all  of  which  are  liable  to  product 
mechanical  irritation.  No  fruit  except  orange,  lemon,  or  peach  juice 
should  be  allowed. 

Osier  recommends  the  following  menu  for  gastric  ulcer  : 

8  A.  M. — Two  hundred  cubic  centimetres  of  Leube's  beef  solution. 

12  M. — Three  hundred  cubic  centimetres  of  milk  gruel  or  peptO' 


THE   ALIMENTARY   CANAL. 


525 


nised  milk  gruel  made  with  ordinary  flour  or  arrowroot,  to  which 
gruel  an  equal  quantity  of  peptonised  milk  is  added. 

4  p.  M. — Buttermilk. 

8  p.  M. — Gruel. . 

In  addition,  rectal  alimentation  is  to  be  given.  The  whites  of 
eight  eggs  may  be  used  in  alternation  with  the  beef  solution. 

After  a  month  of  this  treatment  the  following  articles  are  cau- 
tiously given :  Scraped  beef,  chicken,  fresh  sweetbread,  a  farina- 
ceous pudding  made  with  milk  and  eggs.  This  treatment  should 
last  three  months,  most  of  which  time  is  to  be  spent  in  bed. 

The  rules  for  stimulants  are  that  they  should  be  absolutely  for- 
bidden unless  they  become  necessary  through  exhausting  haemor- 
rhage or  great  weakness,  in  which  event  they  had  better  be  supplied 
through  the  rectum. 

Von  Ziemssen  prescribes  Carlsbad  water  in  order  to  neutralise 
the  acidity  of  the  stomach  and  hurry  its  contents  into  the  duodenum. 
He  recommends  drinking  half  a  pint  to  a  pint  of  this  water  hot  early 
in  the  mornings  during  convalescence. 

Aerated  waters  should  not  be  recommended.  The  gas  is  apt  to 
distend  the  stomach,  and  the  carbonic  acid  is  believed  to  be  irrita- 
ting to  the  raw  surface  of  the  ulcer. 

Cancer  of  the  Stomach. 

In  cancer  of  the  stomach,  prolongation  of  the  patient's  life  and 
personal  comfort  depends  more  upon  the  dietetic  than  any  other 
form  of  treatment.  Nourishment  should  be  given  in  a  concentrated 
and  predigested  form,  and  where  pyloric  obstruction  exists,  in  a 
condition  which  admits  of  direct  absorption  from  the  stomach 
wall.  It  is  necessary  to  avoid  food  that  is  liable  to  remain  long  in 
the  stomach  and  excite  nausea  and  vomiting,  which  may  in  turn  de- 
velop severe  pain  or  fatal  haemorrhage,  and  to  prohibit  anything 
which  by  undue  fermentation  might  cause  distention  and  stretch  an 
already  thinned  gastric  wall  to  the  point  of  perforation. 

Osier  mentions  that  in  organic  disease  of  the  stomach  pain  usu- 
ally begins  soon  after  eating  and  continues  until  its  digestion  is  over 
or  vomiting  occurs,  but  sometimes  the  pain  of  carcinoma  may  be  re- 
lieved by  ingestion  of  food. 

Aside  from  the  local  difficulties  of  digestion  in  gastric  carcinoma  in 
the  immediate  vicinity  of  the  stomach  wall,  the  gastric  juice  is  either 
deficient  in  amount  or  altered  in  composition,  and  the  hydrochloric 
acid  may  be  totally  absent.  Hence  stomach  digestion  cannot  be 
counted  upon  at  all,  and  it  is  important  to  digest  all  food  by  arti- 
ficial processes.  Boas  and  D.  D.  Stewart  claim  that  lactic  acid  may 
be  found  in  carcinoma  of  the  stomach  after  a  test  meal  of  flour  soup 
has  been  given,  when  hydrochloric  acid  is  absent. 


526 


DIET  IN   DISEASE. 


In  nearly  all  cases  nutrient  enemata  will  sooner  or  later  be  re- 
quired either  as  an  adjunct  to  stomach  feeding  or  to  replace  it  en- 
tirely. Owing  to  the  importance  of  this  subject,  it  will  be  separately 
discussed  (see  page  375). 

If  much  pain  follows  the  ingestion  of  any  food,  or  if  there  is  a 
tendency  to  haemorrhage,  stomach  feeding  should  be  entirely  replaced 
in  this  manner.  In  no  other  disease  can  life  be  supported  for  so 
long  a  time  and  so  comfortably  upon  exclusive  rectal  alimentation. 
After  a  few  days  of  rest  secured  by  substitution  of  enemata  the 
stomach  may  become  less  intolerant  and  food  can  again  be  swal- 
lowed. 

The  exact  nature  and  site  of  a  carcinomatous  lesion  cannot 
always  be  determined,  especially  in  its  early  stages,  and  each  case 
requires  special  study.  Patients  soon  find  by  experience  what  gives 
them  most  distress  and  learn  to  avoid  it.  In  general,  saccharine  and 
farinaceous  foods  should  be  proscribed  because  they  are  normally 
not  digested  in  the  stomach,  and  in  carcinoma  they  linger  and,  aided 
by  the  catarrh  which  is  usually  also  present,  undergo  abnormal  fer- 
mentation with  production  of  gas,  nausea,  and  vomiting.  It  is  usu- 
ally the  case  that  predigested  albumingus  food  is  better  assimilated. 
Digestion  in  such  cases  should  be  watched  from  day  to  day,  and  when 
patients  can  tolerate  a  little  simple  farinaceous  food  without  its  pro- 
ducing eructations  or  increasing  the  gastric  pain  and  discomfort,  it 
may  be  added. 

If  the  new  growth  causes  stricture  of  the  cardiac  end  of  the  stom- 
ach, only  fluid  food  can  be  taken,  and  the  act  of  swallowing  should 
be  studied  to  make  sure  that  dilatation  of  the  oesophagus  is  not  devel- 
oping. If,  on  the  other  hand,  it  constricts  the  pyloric  end,  food  can- 
not pass  on  into  the  intestine,  and  gastric  dilatation  may  result.  It 
then  becomes  highly  important  to  put  into  the  stomach  only  that 
which  can  be  absorbed  from  its  wall.  Such  substances,  besides 
water,  include  peptones,  albumoses,  and  alcoholic  stimulants  (cham- 
pagne, whisky,  and  brandy),  all  which  may  be  taken  up  by  the  cir- 
culation of  the  gastric  wall  in  considerable  quantity.  Albumoses 
would  theoretically  constitute  a  most  useful  food,  being  entirely  pre- 
digested and  ready  for  immediate  absorption  ;  but  practically  patients 
soon  weary  of  such  a  diet,  and  food  of  that  nature  will  not  long  sup- 
port life  when  given  alone.  In  complete  pyloric  obstruction  albumoses 
may  be  prescribed,  and  in  advanced  gastric  dilatation  they  are 
needed.  They  may  be  sometimes  alternated  with  other  foods  with 
advantage. 

If  much  dilatation  exists  without  nausea  or  vomiting,  fluid  foods 
will  sometimes  lie  unabsorbed  in  the  stomach  for  one  or  two  days, 
and  then  several  quarts  of  fluid  will  be  unexpectedly  ejected.  It  is 
consequently  advisable  to   examine  and  percuss  the  stomach  from 


THE   ALIMENTARY   CANAL. 


527 


time  to  time,  to  make  sure  that  nourishment  swallowed  is  not  accu- 
mulating there. 

Exceptionally,  if  the  disease  has  not  progressed  too  far,  patients 
do  best  on  a  dry  diet,  and  finely  chopped  steak,  tender  rare  beef, 
chicken,  scraped  beef,  soft-cooked  or  raw  eggs  may  be  given,  and 
digestion  is  facilitated  by  the  use  of  pepsin  and  hydrochloric  acid  or 
papoid.  If  there  is  no  pyloric  obstruction,  and  if  it  does  not  produce 
nausea  or  pain,  simple  forms  of  starchy  food  may  be  added,  such  as 
dry  bread,  toast,  crackers. 

In  advanced  cases  the  diet  must  be  wholly  fluid  and  concen- 
trated; food  should  be  given  only  in  very  small  quantities — not 
over  one  or  two  teaspoonfuls  at  one  time,  frequently  repeated.  Meat 
extracts,  albumoses,  buttermilk,  pancreatinised  milk,  koumiss,  and 
prepared  egg  albumen  may  be  retained.  The  yolks  of  eggs  are  not 
absorbed  from  the  stomach  on  account  of  the  fat  which  they  con- 
tain. If  possible,  the  diet  should  consist  almost  wholly  of  prepared 
milk. 

Oppolzer  advises  the  use  of  sour  milk  in  cases  of  carcinoma  of 
the  stomach  in  which  there  is  more  or  less  constant  tendency  to  vom- 
iting, and  in  which  ordinary  milk  coagulates  in  the  stomach  in  large 
curds.  Sour  milk  is  much  less  apt  to  form  large  tough  coagulae.  It 
is  usually  better,  however,  in  such  cases  to  pancreatinise  the  milk  or' 
give  it  in  the  form  of  koumiss. 

For  the  control  of  vomiting  there  may  be  also  tried  iced  carbon- 
ated water,  champagne,  bismuth,  morphine,  cocaine,  and  counter- 
irritation.  For  indigestion,  eructations,  or  gaseous  distention,  ant- 
acids and  antifermentatives  are  indicated,  or  pepsin  with  dilute 
hydrochloric  acid. 

For  beverages  red  wine,  dilute  whisky  and  water  or  dry  cham- 
pagne, or  acidulated  drinks  may  be  given  in  the  early  stages.  Ales, 
beers,  and  effervescing  waters  should  be  avoided. 

The  dietetic  treatment  of  cancer  as  conducted  by  Beneke  is  based 
on  the  belief  that  the  growth  will  be  checked  by  diminishing  the 
quantity  of  albuminous  food  and  of  phosphoric  acid  furnished  in  the 
food.  He  finds  that  the  carcinomatous  protoplasm  contains  choles- 
terin  and  also  lecithin,  which  is  related  to  nitrogenous  substances. 
He  also  finds  it  advisable  to  diminish  the  earthy  and  alkaline  phos- 
phates. To  attain  this  end  he  restricts  both  vegetable  and  animal 
foods  which  are  known  to  contain  these  materials  in  abundance,  and 
feeds  his  patient  largely,  but  not  exclusively,  upon  simple  carbo- 
hydrates. 

Beneke's  diet  for  carcinoma  is  given  by  Bauer  as  follows: 

"  Breakfast. — A  strong  infusion  of  black  tea  with  sugar  and  cream, 
a  little  bread  with  plenty  of  butter,  then  some  potatoes  cooked  in 
their  skins,  with  butter.     Cocoa  may  be  substituted  for  tea. 
36 


g  DIET    IN  DISEASE. 

<i  Lunch. Fruit  raw  or  cooked,  English  biscuits  or  a  little  bread 

and  butter,  and  a  glass  of  wine. 

"  Dinner. Fruit  soup  or  wine  soup  with  sago  or  Indian-corn  meal, 

or  potato  soup;  not  more  than  fifty  grammes  of  meat,  fresh  minced ;_ 
potatoes  in  the  form  oi puree,  mashed,  or  plain-boiled;  any  kind  of 
vegetable  roots;  stewed  fruit,  apples  or  plums  with  rice,  or  rice  with 
rum,  salads  and  fruit  ices.  Light  Moselle  or  Rhine  wines  or  cham- 
pagne are  allowed ;  beer,  however,  is  only  to  be  permitted  in  small 
quantities,  on  account  of  its  large  percentage  of  alkaline  phosphates. 

''Afternoon. — Black  tea  with  sugar  and  cream  and  a  little  bread 
and  butter,  and  perhaps,  also,  some  raw  fruit  and  biscuit. 

"  Supper. — Soup  as  at  dinner,  rice  with  fruit,  boiled  potatoes  with 
butter,  or  potato  salad ;  small  quantities  of  sardines  in  oil,  anchovies 
or  fresh  herrings;  buckwheat  gruel  with  wine  and  sugar;  light 
wines." 

This  diet  is  applicable  for  carcinomatous  cases  in  general  rather 
than  for  cancer  of  the  stomach. 

Ewald  says :  "  A  diet  of  starches  and  vegetables  is  more  easily 
borne  than  that  of  meat,  since  the  diminution  in  the  secretion  of 
hydrochloric  acid  causes  the  digestion  of  albumin  and  meat  to  be 
incomplete.  In  most  cases  milk  is  also  poorly  borne,  on  account  of 
the  absence  of  rennet."  When  milk  is  tolerated,  however,  he  advises 
the  addition  of  a  few  drops  of  Cognac  to  each  tablespoonful,  or  the 
use  of  kefir  or  peptonised  milk. 

Oppolzer  claims  that  patients  vomit  less  if  they  take  all  food  cold. 

Many  special  systems  of  diet  have  been  exploited  for  the  treat- 
ment of  cancer  of  the  stomach,  some  of  which  have  proved  of 
occasional  value,  and  have  at  least  the  merit  of  being  based  upon 
scientific  reasoning,  whereas  others  are  pure  quackery.  It  is  almost 
needless  to  say  that  no  such  thing  as  a  dietetic  "  cure  "  for  cancer  ex- 
ists. The  most  that  can  be  expected  of  any  dietetic  system  for  this 
fatal  disease  is  that  it  may  make  the  patient  somewhat  more  com- 
fortable, and  prolong  his  life  perhaps  for  a  few  weeks  or  months  by 
maintaining  better  general  nutrition. 

Lavage  is  sometimes  employed  as  an  adjunct  to  dietetic  treat- 
ment where  much  catarrh  of  the  stomach  or  dilatation  is  present.  It 
may  relieve  some  of  the  symptoms  in  the  early  stages  of  the  disease, 
but  it  should  be  performed  with  great  care,  for  it  is  uncertain  to  what 
extent  the  stomach  wall  may  be  eroded.  I  have  known  of  at  least 
one  case  in  which  a  fatal  result  followed  the  false  passage  of  an 
oesophageal  tube. 

The  surgical  treatment  of  cancer  has  come  to  the  front  of  late 
years  so  much  that  the  dietetic  as  well  as  attempted  medical  treat- 
ment of  this  disease  has  been  relatively  overlooked,  and  the  belief 
that  its  progress  can  be  modified  by  either  of  the  latter  means  is  not 


THE   ALIMENTARY   CANAL. 


529 


very  general.  Unfortunately,  however,  the  results  of  operation  have 
not  been  attended  with  the  success  that  was  anticipated,  and  all 
comes  back  to  the  problem  of  supporting  waning  strength  by  nu- 
trition. 

DiARRHCEA. 

Pathological  Physiology. — Diarrhoea  is  commonly  the  result 
of  excessive  peristalsis.  It  may  also  be  occasioned  by  the  presence 
of  a  large  volume  of  fluid  in  the  intestine,  caused  either  by  lack  of 
absorption  of  an  excess  of  liquid  ingested,  or  oftener  by  hypersecre- 
tion or  failure  to  absorb  the  fluid  of  the  chyme. 

The  exaggerated  peristalsis  is  occasioned — 

1.  By  increased  irritation  of  the  nerves  or  muscles  of  the  intestine, 
due  to  mechanical  stimulation  of  irritant  or  undigested  particles  of 
food  (e.  g.,  the  seeds  of  berries  or  husk  of  corn  grains). 

2.  By  chemical  products  which  are  contained  in  the  food. 

3.  By  abnormal  fermentation,  the  products  of  which  excite  mus- 
cular contractions. 

Diarrhoea  may  be  (a)  acute,  due  to  temporary  errors  in  diet,  tak- 
ing cold,  acute  intestinal  catarrh,  the  ingestion  of  poisons,  overdoses 
of  aperients,  etc.,  or  {b)  chronic,  complicating  some  intestinal  or  other 
malady. 

Acute  diarrhoea  often  subsides  of  itself  if  food  be  withheld  untiL 
the  irritant  matter  has  passed  off  from  the  intestine. 

Chronic  diarrhoea  of  long  standing  requires  great  care  and  pa- 
tience in  treatment. 

Abundant  greenish  fluid  stools  showing  much  bile  pigment  indi- 
cate that  the  stools  have  been  hurried  out  of  the  small  intestine. 
before  digestion  was  complete. 

Of  the  many  forms  of  diarrhoeal  diseases,  the  treatment  of  those 
only  which  are  most  influenced  by  diet  will  be  discussed  in  the  suc- 
ceeding pages.  There  are  a  few  propositions  which  have  general 
application  to  the  different  varieties,  which  will  be  mentioned  here. 

Dietetic  Treatment. — It  is  a  general  rule  to  moderate  the 
quantity  of  food  and  avoid  all  food  likely  to  undergo  abnormal  fer- 
mentation (such  as  sugars),  or  having  a  considerable  residue.  Un- 
irritating  or  bland  substances  only  should  be  taken.  Fruits  and 
vegetables  must  be  wholly  interdicted. 

At  the  commencement  of  an  acute  attack  food  may  be  withheld, 
for  ten  or  twelve  hours,  and  a  little  barley  water  or  arrowroot  gruel 
flavoured  with  a  mere  taste  of  lemon  or  spice  should  then  be  or- 
dered with  one  or  two  tablespoonfuls  of  brandy  in  soda  water.  Mut- 
ton or  chicken  broth  may  next  be  given,  and,  if  desirable,  it  may  be 
thickened  with  boiled  rice,  tapioca,  sago,  or  cracker  crumbs.  Pa-, 
tients  who  are  not  at  the  same  time  "  bilious "  or  vomiting  may 
take  milk  diluted  with  one  third  lime  water. 


530  DIET   IN   DISEASE. 

The  return  to  ordinary  diet  should  be  in  all  cases  gradual,  and 
such  articles  as  milk  toast,  oysters,  well-cooked  macaroni,  boiled 
rice  with  beefsteak  gravy,  the  breast  of  boiled  chicken,  or  a  little 
partridge  in  season,  with  baked  and  mashed  potatoes,  may  be  first 
allowed. 

Loose  stools  sometimes  occur  immediately  after  meals,  the  im- 
pulse for  the  bowels  to  move  coming  so  suddenly  that  the  patient 
scarcely  has  time  to  leave  the  table  for  the  closet.  In  such  cases 
"some  one  article  of  diet  is  at  fault"  (Osier).  The  patient  should 
be  put  upon  a  diet  restricted  mainly  to  meat  and  stale  bread  or  toast 
for  a  few  days,  and  made  to  lie  down  and  rest  immediately  after 
meals.  Taking  food  into  the  stomach  excites  a  reflex  intestinal 
peristalsis,  and  the  intestinal  contents  are  hurried  onward  before  they 
can  be  digested. 

For  the  form  of  diarrhoea  which  occurs  in  hysterical  women,  if  a 
milk  diet  is  not  well  borne.  Osier  recommends  feeding  the  patient 
upon  egg  albumen  exclusively  while  medicinal  antispasmodics  are 
given  to  diminish  peristalsis. 

In  diarrhoeas  demulcent  and  mucilaginous  drinks  are  useful,  and 
they  are  believed  to  coat  the  alimentary  canal  and  protect  it  from 
local  irritation.  It  is  doubtful,  however,  whether  any  such  action 
occurs  beyond  the  stomach. 

DiARRHCEA   IN   INFANTS  AND   YoUNG   CHILDREN. 

Dietetic  Causes. — The  dietetic  causes  of  diarrhoea  in  infants 
and  young  children  may  be  classed  as  due  to — 

1.  Too  frequent  or  irregular  feeding. 

2.  Overfeeding. 

3.  Feeding  with  improper  or  "  spoiled  "  food. 

The  first  and  second  causes  are  commonest  in  early  infancy,  and 
the  third  is  commonest  in  childhood,  although  any  or  all  of  them 
may  operate  at  any  age. 

Children  brought  up  in  the  country  are  much  less  subject  to  diar- 
rhceal  disorders  than  those  raised  in  cities,  owing  to  the  relative 
purity  of  their  milk  and  other  foods,  and  the  greater  resisting 
power  with  which  their  better  general  health  and  vigour  supplies 
them. 

In  a  series  of  nearly  two  thousand  cases  of  fatal  diarrhoea  col- 
lected by  various  observers  (Hope,  Meinert,  Ballard),  only  3  per 
cent  received  the  breast  exclusively.  These  are  very  significant 
data,  and  point  to  the  conclusion  that  the  vast  majority  of  cases  are 
due  solely  to  the  use  of  improper  or  contaminated  food. 

Differences  in  the  mere  chemical  composition  of  the  cow's  milk 
used  for  feeding  are  not  sufficient  to  account  for  the  frequency  of 


THE   ALIMENTARY   CANAL.  53 1 

diarrhcEal  diseases,  and  the  further  conclusion  is  reached,  and  has 
been  sustained  by  bacteriological  research,  that  the  harm  is  caused 
by  noxious  germs. 

Diarrhoea  occurring  in  nursing  infants  must  be  accounted  for  in 
other  ways,  although  germs  may  readily  have  access  to  the  child's 
mouth  from  an  unclean  nipple  or  from  sucking  its  own  soiled 
fingers. 

Aside  from  this,  anything  which  disturbs  the  mother's  digestion 
may  excite  diarrhoea  in  her  baby,  as,  for  example,  improper  food, 
menstruation  or  pregnancy  (rarely),  strong  nervous  influences,  such 
as  grief  or  worry,  great  exhaustion,  extreme  anaemia,  the  use  of  cer- 
tain powerful  drugs. 

Evidently  the  intestine  becomes  stronger  or  less  susceptible  to 
bacterial  poisons  after  the  first  two  years  or  thirty  months  of  life, 
for  the  frequency  of  serious  diarrhoea  lessens,  although  the  child 
often  gets  as  bad  or  worse  milk  to  drink  as  it  had  when  fed  upon  the 
bottle.  It  is  possible  that  a  larger  number  of  germs  are  necessary 
to  cause  infection  than  in  the  tender  period  of  suckling,  but  a  more 
plausible  explanation  is  found  in  the  relative  acidity  of  the  gastric 
juice  at  different  ages.  An  acid  reaction  of  at  least  0.16  per  cent  is 
necessary  to  stop  the  growth  of  most  of  the  bacteria  in  question, 
whereas  Van  Puteren  finds  only  0.08  per  cent  or  less  in  the  infant 
stomach. 

It  has  been  suggested  that  water  may  excite  diarrhoea  by  hur- 
riedly washing  germs  into  the  intestine  which  are  ordinarily  killed 
in  transit  by  the  acid  of  the  stomach.  The  bile  is  reputed  to  be 
antiseptic,  but  Booker  has  found  that  all  bacteria  will  grow  in  a 
lo-per-cent  solution  of  it,  and  it  easily  undergoes  fermentation  from 
decomposition  of  its  mucus.  Its  antiseptic  reputation  rests  upon 
the  fact  that  it  stimulates  peristalsis,  keeps  the  bowels  moving,  and 
thereby  prevents  food  from  accumulating  and  fermenting  abnor- 
mally. 

In  large  cities,  where  women  among  the  poor  are  obliged  to  go 
out  to  work  by  the  day,  they,  as  a  rule,  suckle  their  infants  for  only 
the  first  six  months,  or  if  for  a  longer  period,  they  add  other  food  or 
have  their  babies  bottle-fed  by  a  neighbour  or  in  a  "  day  nursery  " 
during  the  hours  in  which  they  themselves  are  away  from  home. 
Hand-fed  children  are  almost  always  given  more  than  they  can 
assimilate. 

As  the  infant  grows  older  it  is  brought  to  the  family  table,  and 
when  a  year  and  a  half  old  it  is  not  seldom  stuffed  with  any  articles 
from  it.  Beer,  sausages,  bananas,  potatoes,  tea,  and  coffee — all  are 
given. 

Overfeeding  and  the  use  of  such  harmful  food  maintains  almost 
constant  dyspepsia,  and  if  it  does  not  itself  cause  diarrhoea  it  predis- 


532  DIET   IN   DISEASE. 

poses  to  it  by  keeping  the  alimentary  canal  in  a  constant  state  of 
irritation  or  hyperaemia,  so  that  slight  additional  factors  excite  the 
trouble,  and  bacteria  find  a  fertile  soil  in  which  to  develop. 

In  older  children  foods  which  are  among  the  commoner  causes 
of  diarrhoea  are  unripe  or  overripe  fruits  of  all  kinds,  berries  with 
seeds,  vegetables  having  a  tough  outer  envelope,  such  as  old  peas, 
beans,  and  green  corn,  imperfectly  cooked  cereals,  like  coarse  hom- 
iny, rice,  or  oatmeal,  nuts,  raisins,  and  dried  currants.  Generally 
speaking,  diarrhoea  is  more  apt  to  be  caused  by  fruits  and  tough 
meats  imperfectly  masticated  than  by  vegetables. 

Examination  of  the  Stools. — In  all  serious  cases  the  stools 
should  be  examined,  if  possible,  microscopically,  to  determine  the  de- 
gree of  digestion  and  absorption  of  the  food.  The  chief  abnormal 
ingredients  are  fat,  bacteria,  mucus,  casein,  starch,  and,  if  meat  has 
been  eaten,  muscle  fibres.  The  green  diarrhoea  of  infancy  is  usually 
of  microbic  origin. 

Fat. — The  normal  percentage  of  fat  which  the  stools  contain  is, 
according  to  Uffelmann's  analysis,  fourteen  on  the  average,  but  in 
diarrhoea  with  intestinal  dyspepsia  it  rises  often  to  forty  or  fifty,  and 
it  has  reached  sixty-four.  The  fat  appears  in  minute  white  flocculi, 
varying  in  size  from  that  of  a  pin's  head  to  a  split  pea.  These  small 
masses  are  often  mistaken  for  casein,  but  the  careful  researches  of 
Wegscheider,  Baginsky,  and  others  have  demonstrated  them  to  be 
composed  of  inspissated  fat  and  colonies  of  bacteria.  It  is  an  easy 
matter  to  distinguish  them  from  casein,  as  they  alone  are  dissolved 
by  the  addition  of  a  few  drops  of  alcohol  and  ether. 

Bacteria. — The  commonest  bacteria  of  infant  stools  are  the 
Bacterium  lactis  aerogenes  and  the  Bacterium  coli  commune.  In  fact, 
these  two  normal  varieties  are  the  only  constant  kinds  in  milk- 
fed  babies  (Escherich),  although  Booker  has  found  in  different  cases 
of  infantile  diarrhoea,  and  especially  cholera  infantum,  forty  varieties 
in  all  which  bear  no  special  relation  to  particular  foods.  The  first- 
named  germ  occurs  only  when  milk  has  been  ingested,  for  it  thrives, 
as  its  name  indicates,  upon  lactose.  Its  chief  site  is  the  small  intes- 
tine, where  it  causes  milk  to  ferment.  The  bacterium  coli  commune, 
on  the  contrary,  elects  the  large  intestine  and  thrives  upon  the  resi- 
due of  digested  food.  .Booker  is  of  the  opinion  that  the  influence  of 
the  various  pathogenic  germs  in  the  production  of  diarrhoea  is  at- 
tributable more  to  alteration  of  the  food  and  intestinal  contents 
than  to  direct  irritation  of  the  intestinal  wall. 

Casein. — Undigested  casein  is  a  less  common  ingredient  of  the 
stools  than  was  supposed  before  the  above-described  observations 
were  made.  When  present  it  is  in  the  form  of  smooth,  somewhat 
hard  masses,  often  of  a  yellow  or  yellowish-white  colour  without, 
but  white  when  broken  open.     They  are  usually  friable,  and  have  a 


THE   ALIMENTARY  CANAL. 


533 


cheesy  odour.  They  may  present  a  semitransparent  or  horny  ap- 
pearance. 

Starch. — Starch  granules  appear  in  the  stools  very  often  when 
imperfectly  cooked  amylaceous  food  has  been  eaten,  such  as  oat- 
meal, barley,  potatoes,  bread,  etc. 

They  are  recognised  by  the  microscope,  and  by  the  addition  of  a 
solution  of  iodine,  which  colours  the  stools  dark  blue. 

Meat  Fibre. — Muscle  fibres  are  easily  recognisable  by  micro- 
scopic examination,  but  not  otherwise. 

Dietetic  Treatment. — The  principles  of  dietetic  treatment  of 
simple  bacterial  or  mycotic  diarrhoea  occurring  in  infants  under  two 
years  of  age  are,  first,  to  give  the  alimentary  canal  rest,  and,  sec- 
ondly, to  give  food  which  is  very  thoroughly  absorbed,  leaving  the 
least  possible  residue  of  waste.  All  food  is  to  be  withheld  for  from 
twelve  to  twenty-four  hours,  and  cool  sterilised  water  or  barley 
water,  and  cracked  ice  (if  pure)  is  given  to  allay  thirst.  The  child 
will  not  suffer  from  lack  of  food.  It  will  suffer  much  more  with  it. 
Stimulants  are  usually  needed,  and  half  a  teaspoonful  of  champagne 
or  ten  to  thirty  drops  of  brandy,  well  diluted,  may  be  prescribed. 

After  the  interval  mentioned  food  is  to  be  cautiously  adminis- 
tered, but  in  less  than  the  usual  quantity.  Unless  the  infant  can 
have  breast  milk,  which  is  usually  most  desirable  for  it,  it  is  best  to 
give  no  milk  at  all,  but  instead  such  articles  as  whey,  thin  mutton  or 
chicken  broth,  barley  gruel,  or  egg  albumen  beaten  in  half  a  pint  of 
cold  water  to  which  a  teaspoonful  of  brandy  and  a  pinch  of  salt  is 
added.  After  two  or  three  days  of  this  diet,  if  the  child  continues 
to  improve,  the  milk  diet  given  before  the  illness  is  to  be  gradually 
resumed,  but  the  feeding  should  be  watched  with  care  for  at  least 
a  week. 

Escherich  lays  great  stress  upon  the  importance  of  regulating 
the  diet  by  the  stools,  but  his  views  are  not  accepted  by  equally 
good  authorities.  He  says  that  if  the  stools  are  foul  and  offensive, 
showing  evident  alkaline  putrefaction,  albumen  should  not  be  given, 
but  rather  dextrinised  starchy  foods  and  sugar.  On  the  other  hand, 
if  the  stools  are  sour  or  acid,  but  not  fetid,  and  less  offensive,  broths 
and  egg  albumen  are  indicated. 

To  older  children,  when  diarrhoea  has  been  excited  by  eating  im- 
proper food,  unless  the  bowels  have  been  already  very  thoroughly 
evacuated,  or  if  signs  of  intestinal  irritation  continue,  it  is  best,  as 
with  adults,  to  give  castor  oil  and  opium  in  the  form  of  paregoric  or 
Dover's  powder,  and  then  to  feed  the  child  upon  the  principles  laid 
down  above  for  infants.  As  a  rule,  it  is  best  to  avoid  "  prepared 
foods"  or  patented  infant  foods,  and  good  nutritious  home-made 
fresh  broth  from  well-selected  lean  mutton,  chicken  or  beef  broth, 
is  decidedly  to  be  preferred. 


--,^  DIET   IN   DISEASE. 

Entero-colitis  IN  Infants  and  Children.— Summer 

DiARRHCEA. 

Summer  diarrhoea  is  exceedingly  fatal  among  infants  in  hot 
weather  in  densely  populated  localities,  and  they  require  very  care- 
ful feeding  for  this  disease.  Intractable  cases  are  prolonged  for 
several  weeks,  with  more  or  less  vomiting,  diarrhoeal  mucous  stools, 
fever,  and  meteorism,  and  a  variety  of  complications  supervene ; 
hence  there  is  ample  opportunity  for  the  exercise  of  dietetic  skill. 

Prevention. — Entero-colitis  is  a  subacute  milk  infection  resem- 
bling the  acute  form,  cholera  infantum,  but  it  is  less  violent,  although 
much  more  prevalent.  It  is  produced  by  toxines  developed  by  the 
activity  of  bacteria  in  the  foods,  and  it  is  therefore  to  a  large  extent 
preventable,  and  most  easily  so  by  continued  and  exclusive  breast 
nursing. 

The  preventive  treatment  for  weanlings  in  nurseries  where  there 
are  several  children  consists  in  absolute  cleanliness  and  antisepsis, 
and  the  nurse  must  be  made  to  realise  the  necessity  of  disinfecting 
diapers  and  her  own  hands  at  once,  and  she  must  never  handle  either 
food  or  food  utensils  with  soiled  hands,  for  by  neglect  of  these  sim- 
ple precautions  the  germs  are  easily  passed  on  from  one  child  to 
another.  When  cow's  milk  is  used  in  hot  weather  it  must  always  be 
sterilised  or  Pasteurised. 

Dietetic  Treatment. — If  the  child  is  still  nursing,  and  the 
mother's  milk  is  found  to  disagree,  a  wet  nurse  should  be  secured 
whenever  possible.  If  the  child  is  bottle  fed,  great  care  should  be 
taken  to  introduce  only  sterile  food  into  the  stomach.  If  the  child 
is  fairly  strong  and  well  nourished  at  the  commencement,  it  is  better 
to  withhold  all  food  for  twenty-four  or  thirty-six  hours,  and  merely 
give  a  little  barley  water  or  some  equally  bland  beverage.  In  any 
event  it  is  best  to  abandon  milk  and  its  preparations  entirely  for 
two  or  three  days.  In  this  manner  the  intestinal  germs  which  are 
causing  the  mischief  are  starved  out  or  replaced  by  others  which 
are  comparatively  innocuous. 

There  are  many  cases  of  enteritis  in  children  in  which  milk 
wholly  disagrees,  even  when  Pasteurised  or  pancreatinised,  appar- 
ently because  the  casein  is  not  properly  digested  in  the  stomach,  and 
in  such  cases  the  casein  should  be  prevented  from  passing  through 
the  alimentary  canal  in  tough  and  irritating  coagulae. 

Fresh  meat  broths  (beef,  mutton,  or  veal),  pressed-meat  juice,  and 
egg-albumen  solution  with  ten  to  thirty  drops  of  diluted  whisky  or 
good  brandy,  are  to  be  given  in  lieu  of  all  milk.  Children  a  year  or 
more  old  may  have  gruels  of  arrowroot,  barley,  or  rice,  but  commer- 
cial baby  foods  and  patented  meat  extracts  must  be  omitted.  Mix- 
tures of  cream  and  water  are  sometimes  recommended. 


THE  ALIMENTARY  CANAL. 


535 


It  is  important  to  give  nourishment  in  very  moderate  quantity, 
one  or  two  teaspoonfuls  at  a  time,  to  prevent  overfilling  of  the 
stomach. 

For  older  children  a  little  scraped  beef  may  be  prescribed  three 
times  a  day ;  and  they  may  be  allowed  to  drink  whey.  If  vomiting 
is  present  with  much  prostration,  one  or  two  teaspoonfuls  of  cold 
champagne  may  be  given. 

After  several  days,  but  not  until  the  symptoms  have  well-nigh 
disappeared,  a  very  gradual  return  to  Pasteurised  milk  is  permis- 
sible. 

In  those  cases  in  which  children  lose  all  appetite  or  infants 
persistently  refuse  to  take  the  bottle,  the  prognosis  is  extremely 
unfavourable,  and  recourse  must  be  had  to  rectal  feedinjg  and 
stimulation. 

In  every  protracted  case  an  exact  record  must  be  kept  of  the 
quantity  of  food  taken,  and  no  general  report  should  be  accepted 
from  the  nurse  that  the  child  is  simply  "  feeding  well."  Frequent 
weighing  and  comparison  with  the  amount  of  food  ingested,  com- 
bined with  personal  observation  of  the  stools,  are  the  best  guides  for 
the  physician  to  follow  in  regulating  the  diet,  and  they  should  never 
be  neglectfed. 

During  convalescence  older  children  must  be  carefully  watched 
to  see  that  they  do  not  surreptitiously,  or  through  ignorance  of  their 
nurses,  obtain  unwholesome  food.  Such  articles  as  potatoes,  toma- 
toes, and  other  fresh  vegetables,  coarse  cereals,  like  oatmeal,  wheaten 
grits,  and  corn  meal,  must  be  forbidden,  as  well  as  fruits.  Holt  has 
seen  a  fatal  issue  from  eating  a  few  raisins. 

Cholera  Infantum,  or  Acute  Milk  Infection. 

Cholera  infantum  is  a  gastro-intestinal  disease  of  violent  acute- 
ness,  characterised  by  severe  vomiting,  purging  by  serous  stools, 
collapse,  very  rapid  emaciation,  thirst,  fever,  and  other  symptoms. 
According  to  Holt,  between  2  and  3  per  cent  of  the  cases  of  diarrhoeal 
disease  in  infants  are  cholera  infantum. 

It  does  not  occur  in  nursing  infants,  but  only  in  those  fed  by 
artificial  means.  No  specific  micro-organism  has  been  detected, 
although  various  germs  abound  in  the  watery  evacuations.  Vaughan 
believes  it  to  be  due  to  tyrotoxicon,  which  he  has  demonstrated  in 
cow's  milk,  and  which  exists  only  in  milk  or  some  modified  form  of 
it,  such  as  condensed  milk,  or  baby  food  made  in  part  of  milk. 

The  disease  prevails  especially  in  hot  weather,  and  is  so  rapidly 
fatal,  usually  within  one  or  two  days,  that  very  prompt  and  vigorous 
treatment  is  imperative. 

Dietetic  Treatment. — The  giving  of  milk  in  any  form  must  be 
immediately  and  peremptorily  stopped,  and,  as  Vaughan  says  :  "  Pre- 


53<5 


DIET   IN   DISEASE. 


pared  baby  foods  should  be  thrown  out  of  the  window.  Acute  milk 
infection  is  poisoning,  with  a  substance  more  powerful  and  deadly 
than  white  arsenic."  The  poison  must  therefore  be  washed  out ; 
and  no  matter  how  much  vomiting  and  diarrhoea  have  already  oc- 
curred, the  stomach  must  be  cleansed  by  lavage,  and  the  colon  must 
be  irrigated  by  at  least  a  gallon  of  warm  Castile  soapsuds  and  water, 
after  which  cool  water  with  fifteen  to  thirty  grains  of  tannic  acid  to 
the  pint  should  be  injected  (Vaughan),  with  the  object  of  precipi- 
tating poisonous  proteids.  The  irrigation  has  a  further  advantage 
in  that  it  replenishes  by  absorption  a  portion  of  the  water  which  has 
been  rapidly  drained  from  the  system  by  the  violent  purging,  as  in 
the  case  of  Asiatic  cholera,  and  the  loss  of  which  causes  insatiable 
thirst.  The  lavage  allays  gastric  irritability,  and  alcoholic  stimula- 
tion must  then  be  ordered  in  the  form  either  of  half  a  teaspoonful  of 
iced  champagne  or  from  ten  to  fifteen  drops  to  a  teaspoonful  or 
more  of  whisky  or  good  brandy,  diluted  in  water  or  Vichy. 

From  four  to  six  or  eight  ounces  may  be  given  in  twenty-four 
hours  to  avert  collapse.  If  necessary,  the  brandy  is  to  be  given  by 
rectum,  or  the  whisky,  in  extreme  cases,  by  hypodermic  injection. 

Accessory  means  are  bathing  in  warm  mustard  water  and  friction. 
No  nourishment  except  the  alcohol  is  allowable  for  at  least  twenty- 
four  hours,  when  warm  meat  juice,  koumiss,  matzoon,  pancreatinised 
meat  broths,  or  egg  albumen  with  whisky  is  to  be  prescribed  in  tea- 
spoonful doses  every  half  hour  or  hour.  For  a  day  or  two  this  diet 
will  sufifice,  and  milk  should  not  be  again  given  until  the  expiration 
of  that  time,  when  the  ordinary  previous  diet  may  be  cautiously  re- 
sumed. 

Older  children  may  be  allowed  to  have  junket  and  scraped  beef 
which  has  been  squeezed  through  a  sieve. 

Cholera  Morbus.— Acute  Catarrhal  Enteritis  in 

Adults. 

Cholera  morbus  may  be  caused  by  the  ingestion  of  indigestible 
foods  or  improper  drink,  such  as  polluted  water,  or  water  or  beer 
drunk  in  large  quantity  after  long-continued  thirst,  or  chilling  after 
excessive  exercise  and  perspiration.  An  attack  may  be  excited  by 
unripe  fruit  and  vegetables,  such  as  green  apples,  watermelons,  cu- 
cumbers, or  nuts. 

Dietetic  Treatment. — The  patient  must  be  kept  quiet  in  bed, 
well  covered,  and  in  severe  cases  it  may  be  advisable  to  give  no  food 
for  the  first  twenty-four  hours,  after  which  the  diet  should  be  very 
light,  consisting  of  meat  broth  or  of  pancreatinised  milk  with  lime 
water  in  the  proportion  of  one  third  of  the  latter,  given  alone  or  with 
a  little  boiled  rice  or  milk  toast.  Brandy  and  soda  or  champagne 
may  be  prescribed.     The  desire  to  drink  water  constantly  should  be 


THE   ALIMENTARY   CANAL. 


537 


restrained,  as  it  tends  to  keep  the  contents  of  the  intestine  too  fluid 
and  increases  the  diarrhoea.  Thirst  may  be  relieved  by  cracked  ice, 
very  weak  cold  tea  without  sugar,  or  oatmeal  water.  When  the  pa- 
tient is  first  seen,  if  there  is  evidence  of  accumulation  of  irritating 
food  in  the  intestine  which  has  not  been  wholly  eliminated  by  the 
diarrhoea,  it  is  advisable  to  evacuate  the  bowel  with  a  dose  of  castor 
oil  or  salts. 

The  following  day,  if  diarrhoea  and  vomiting  have  ceased,  the 
diet  may  be  increased  slowly ;  otherwise  it  must  be  still  restricted  to 
broths  and  milk.  Among  the  foods  which  may  be  first  allowed  are  a 
soft-cooked  egg,  raw  oysters,  scraped  beef  with  soda  crackers  or 
toast,  and  well-boiled  rice.  If  the  attack  has  lasted  but  a  day  or 
two,  the  patient  may  soon  return  to  his  normal  diet ;  but  if  it  has 
been  protracted,  or  if  he  has  been  much  weakened  by  it,  he  must 
observe  caution  in  eating  for  several  days.  The  diet  for  convales* 
cence  given  on  page  395  may  then  be  followed. 

Chronic  Enteritis  in  Adults.— Chronic  Intestinal 
Catarrh. — Chronic  Colitis, 

In  severe  cases  it  is  often  advisable  to  put  the  patient  upon  a 
milk  diet  for  several  weeks.  Except  in  tuberculous  subjects  this  is 
often  successful  in  effecting  a  cure.  The  milk  may  be  skimmed  or 
boiled  and  diluted  with  lime  water.  As  a  rule,  fatty  and  saccharine 
food  is  forbidden,  and  farinaceous  food  should  be  restricted  in 
quantity.  The  fats  first  fail  of  digestion  in  the  intestine,  and  later 
other  foods.  Patients  must  be  especially  instructed  to  take  their 
meals  very  slowly  and  masticate  sufficiently.  The  diet  should  con- 
sist chiefly  of  bread  and  lean  meats — foods  which  leave  the  least 
residue.  Scraped  beef,  beef  meal,  and  beef  peptonoids  are  useful. 
The  intestinal  indigestion  may  be  improved  by  the  use  of  pancreatic 
extracts  with  bicarbonate  of.  sodium.  The  food  may  be  pancrea- 
tinised  before  it  is  eaten,  or  pancreatin  may  be  given  in  keratin- 
coated  pills  designed  to  remain  undissolved  until  they  have  reached 
the  small  intestine.  The  stools  should  be  watched  for  undigested 
particles  of  food,  muscle  fibres,  etc. 

If  emaciation  continues  with  an  exclusive  diet  of  animal  food  it 
may  be  best  to  give  oatmeal  porridge  or  mush  which  is  predigested 
with  diastase  or  malt  extract.  Baked  potatoes  may  be  similarly 
treated. 

Foods  to  be  avoided  are  very  rich  milk,  green  vegetables,  raw 
acid  fruits,  dried  fruits  and  nuts,  richly  cooked  acid  or  fat  dishes, 
crustaceans,  pork,  veal,  coarse  bread,  pastry,  sweets,  and  desserts  of 
all  kinds. 

In  milder  cases  in  which  there  is  more  or  less  constipation  with 
intestinal  catarrh,  it  is  important  to  regulate  the  bowels,  and  this 


53B 


DIET   IN  DISEASE. 


may  be  done  in  part  by  the  character  of  the  food,  also  by  system- 
atic exercise,  both  active  and  passive.  Mild  calisthenics,  massage 
of  the  limbs  and  the  abdominal  wall,  combmed  with  abundant  fresh 
air,  daily  bathing  in  cold  water,  and  friction  of  the  skin,  are  all  use_- 
ful  aids  to  treatment. 

There  are  cases  of  chronic  colitis  in  adults  which  do  not  improve 
upon  any  diet,  and  after  trying  a  great  variety  of  foods  the  patients 
seem  to  get  on  even  better  for  a  time  on  a  mixed  diet  of  consider- 
able diversity.  ^ 

Alcoholic  stimulants  should  be  given,  and  the  best  forms  are 
claret,  sherry,  or  brandy,  all  diluted  to  two  or  three  times  their 
bulk  with  Apollinaris  or  plain  water.  See  recommends  the  Tannin 
Wine  of  St.  Raphael. 

Some  patients  are  considerably  benefited  by  residence  for  a  few 
weeks  at  one  of  the  alkaline  mineral  springs. 

Chronic  Intestinal  Indigestion  in  Children. 

Chronic  intestinal  indigestion  in  children  should  be  treated  by 
dieting  rather  than  by  medicines.  Diligent  inquiry  must  be  made 
into  the  cause  of  the  trouble,  and  the  diet  must  be  regulated  ac- 
cordingly. The  stools  and  the  urine  must  always  be  carefully  ex- 
amined. If  the  former  are  hard,  white,  and  lumpy,  if  they  are  too 
loose  and  contain  undigested  coagulse  of  casein  and  drops  of  fat,  or 
if  they  are  sour  from  lactic-acid  fermentation,  the  milk  is  certainly 
disagreeing.  If  the  child  is  nursing,  the  mother's  milk  may  be  at 
fault.  If  the  woman  is  worried,  exhausted,  or  possibly  pregnant,  or 
suffering  from  insomnia,  menstrual  disorder,  phthisis,  or  other 
chronic  ailment,  or  if  lactation  is  too  long  continued,  her  milk  must 
be  replaced  by  that  of  a  good  wet  nurse,  or,  failing  this,  by  the  bot- 
tle. This  change  will  often  cure  the  indigestion  at  once.  It  may 
be  that  the  infant  is  simply  overfed,  or  fed  too  often.  The  excess 
of  milk  fails  to  be  absorbed,  undergoes  lactic  acid  fermentation, 
produces  gas  with  abdominal  distention  and  diarrhoea  or  irregular 
passages,  together  with  loss  of  weight,  fretfulness,  and  other  symp- 
toms. If  the  child  is  being  fed  upon  a  mixed  diet  with  milk  and 
one  of  the  prepared  infant  foods,  such  as  Mellin's,  Ridge's  Horlick's, 
etc.,  the  difficulty  may  be  with  either  the  proteid  or  the  carbohy- 
drate elements,  but  the  prepared  foods  had  better  be  abandoned. 
It  is  easy  to  ascertain  which  is  at  fault  by  confining  the  diet  ex- 
clusively for  a  few  days  to  one  or  the  other  of  these  classes  of 
foods,  and  noting  the  effect  on  the  bowels.  Moreover,  proteid 
intestinal  indigestion  usually  produces  offensive  alkaline  feculent 
stools,  while  carbohydrate  indigestion  causes  acid  stools  with  more 
flatus.  Of  course  both  classes  of  indigestion  may  coexist  in  the 
intestine,  but  the  difficulty  is  primarily  with  one  sort  or  the  other, 


THE   ALIMENTARY   CANAL. 


539 


and  hence  the  advantage  of  substituting  for  the  mixed  diet  a  more 
elementary  one.  In  place  of  milk,  egg  albumen,  pressed-beef  juice, 
or  meat  broths  are  to  be  given.  Or  if  these  proteids  are  not  di- 
gested, the  diet  should  consist  for  a  few  days  of  barley  or  rice 
gruel,  or  gruels  of  "  torrefied  starch  " — i.  e.,  wheat  flour  which  has 
been  boiled  or  roasted  in  order  to  burst  the  starch  granules  and 
partially  convert  the  granulose  into  dextrin.  The  digestion  is  carried 
still  further  by  the  use  of  diastase  or  malt  extract,  or  malted  milk 
may  be  given. 

A  mixture  of  cream  and  water  (page  460)  is  well  tolerated  in 
some  cases,  or  peptonised  milk  and  various  other  preparations  of 
milk  may  be  given ;  but  at  present  peptonised  milk  is  less  in  vogue 
than  formerly,  as  its  power  of  restoring  emaciated  tissues  has  been 
seriously  called  in  question.  "  Modified  "  or  "  humanised  "  milk  is 
to  be  preferred  (page  78). 

Older  children  may  have  beef  or  chicken  jelly,  scraped  beef, 
etc.  It  is  well  to  avoid  monotony  of  diet,  lest  the  appetite  fail 
entirely. 

Chronic  Gastro-intestinal  Catarrh. — Chronic  Entero- 
colitis.— Chronic  Diarrhcea  in  Children, 

These  conditions  in  children  should  be  treated  by  very  careful 
regulation  of  the  diet.  Parents  are  apt  to  be  ignorant  in  regard  to 
this  matter,  and  strict  written  rules  should  be  furnished  to  them. 
Children  should  be  fed  at  regular  intervals  at  least  four  times  a 
day,  in  order  that  the  quantity  of  food  given  each  time  may  not  be 
too  much.  They  must  not  be  given  acid  food,  such  as  pickles,  or 
indigestible  substances  of  any  kind,  or  fruit.  Many  cases  do  best 
when  put  upon  a  milk  diet  for  several  weeks,  or,  if  this  is  not  expe- 
dient, peptonised  solutions  or  pancreatinised  food  may  be  substi- 
tuted in  part.  Beef  broth  should  not  be  given  exclusively,  on 
account  of  its  occasional  tendency  to  increase  diarrhoea.  If  the 
stools  contain  much  fat  it  is  an  indication  that  the  pancreatic  and 
biliary  secretions  are  deficient,  and  the  use  of  pancreatin  is  then  of 
special  service. 

These  children  cannot  digest  sugars,  starches,  or  fats  very  thor- 
oughly, although  cod-liver  oil  may  be  assimilated,  and  when  it  is 
it  constitutes  a  valuable  food.  It  does  not  necessarily  increase 
diarrhoea,  and  it  may  even  check  it  indirectly  by  improving  nu- 
trition. 

Among  foods  which  may  be  allowed  to  older  children  as  im- 
provement begins  are  raw  oysters,  boiled  or  broiled  fresh  fish, 
minced  beef  and  chicken,  soft-cooked  eggs,  soda  crackers,  bread 
and  milk,  toast,  thin  bread  and  butter,  blancmange,  custard,  junket, 
and  wine  jelly.     Sometimes  the  child  continues  to  emaciate  upon  a 


CAO  I^IET   IN   DISEASE. 

diet  of  animal  broths  and  meats,  and  fails  to  digest  either  eggs  of 
milk.  In  such  cases  pancreatinised  mush  or  some  simple  cereal  may 
be  given  with  malt  extract,  and  among  vegetables  which  may  some- 
times be  allowed,  if  diarrhoea  has  ceased,  are  asparagus,  spinach, 
stewed  celery,  cauliflower,  and  thoroughly  baked  potatoes  with  a  little 
salt  and  butter  well  rubbed  in. 

Hot  water  should  be  recommended  before  meals  if  the  child  will 
take  it.  It  may  be  given  a  faint  flavour  of  some  spice,  such  as 
cinnamon  or  clove,  and  whey  is  an  excellent  beverage.  Some  chil- 
dren become  very  fond  of  koumiss,  but  it  is  expensive  unless  home- 
made (page  70). 

If  the  child  is  much  reduced  in  flesh  and  strength,  a  half  tea- 
spoonful  of  brandy  three  times  a  day  makes  an  appropriate  stimu- 
lant, or  if  its  taste  is  objected  to,  port  wine  may  be  prescribed. 
Many  of  these  children  become  strikingly  emaciated,  and,  in  spite 
of  all  dietetic  regimen,  the  skin  is  dry  and  wrinkled,  and  care  should 
be  taken  to  improve  its  nutrition.  This  may  be  done  by  tepid  baths 
before  bedtime  and  gentle  friction,  and  by  inunctions  of  three  or  four 
drachms  of  warm  melted  cacao  butter  or  warm  olive  oil  or  cod-liver 
oil,  to  be  rubbed  in  over  the  extremities  and  parts  of  the  trunk  other 
than  the  abdomen.  In  this  way  a  very  little  nourishment  may  be 
rubbed  into  the  circulation,  although  the  main  benefit  of  the  inunc- 
tion consists  in  improving  the  condition  of  the  skin  by  local  action,- 
and  in  preventing  excessive  heat  loss,  to  which  poorly  nourished 
children  are  prone. 

Massage  should  be  given  for  a  quarter  of  an  hour  every  morning. 
It  may  be  applied  over  the  entire  body,  unless  there  is  much  diar- 
rhoea, when  the  abdominal  wall  should  be  omitted. 

Simple  Atrophy. — Marasmus. 

Marasmus  is  a  form  of  starvation  occurring  chiefly  in  artificially 
fed  infants,  but  also  in  those  at  the  breast,  in  whom  there  is  great 
wasting  of  the  muscular  and  other  soft  tissues,  and  sometimes 
catarrh  of  the  alimentary  canal.  The  food  is  either  too  limited  in 
quantity,  is  indigestible,  or  else  is  supplied  in  a  form  in  which  the. 
ingredients  are  not  properly  balanced.  Breast-fed  children  are  more 
apt  to  suffer  from  insufficient  quantity,  and  band-fed  infants  from 
improper  quality  of  food  and  overfeeding.  "  Food  upon  which  a 
child  has  thrived  for  three  or  four  months,  perhaps,  can  become 
unsuitable,  and  consequently  lead  to  wasting  if  the  digestive  powers 
be  suddenly  reduced  by  an  intercurrent  disease  "  (Louis  Starr). 
The  treatment  of  marasmus  is  therefore  essentially  dietetic,  and 
the  reader  is  referred  to  the  general  directions  for  infant  feed- 
ing. No  detail  should  be  considered  too  trivial  for  the  physi- 
cian's personal  attention.     If   nursed,  the    mother    or   wet   nurse's 


THE  ALIMENTARY  CANAL. 


541 


milk  should  be  examined  for  richness  in  cream  and  curd.  If  hand- 
fed,  the  most  scrupulous  care  must  be  taken  to  secure  antiseptic 
cleanliness,  and  milk  or  milk  and  meat  juice  should  be  the  staple 
foods,  to  the  exclusion  of  all  farinaceous  articles  and  patent  "  baby 
foods."  The  disease  is  commonest  in  the  first  year  of  life,  but 
may  occur  in  the  second,  and  its  effects  in  enfeebling  the  consti- 
tution may  last  much  longer.  It  is  just  at  this  period  that  mothers 
— for  reasons  of  supposed  economy  or  expediency — are  tempted  to 
supplant  the  only  natural  infant  food  (milk)  with  all  sorts  of  prepared 
foods.  It  is  because  they  do  not  know  how  to  prepare  cow's  milk 
properly  and  adapt  it  to  the  baby's  needs  that  they  substitute  or  add 
artificial  foods  according  to  the  "  directions  on  the  bottle." 

All  milk  should  be  peptonised,  sterilised,  or  Pasteurised  (page  75), 
and  lime  water  or  barley  water  are  the  best  diluents,  the  former 
being  preferred  if  there  is  vomiting  or  acid  eructation.  (For  the 
correct  degree  of  dilution  according  to  age,  see  Infant  Feeding.)  If 
good  top  milk  cannot  be  obtained,  one  or  two  tablespoonfuls  of 
cream  with  a  tealpoonful  of  milk  sugar  is  to  be  added  to  each 
bottle.  Some  infants  do  better  for  a  short  time  upon  a  cream  and 
water  mixture. 

In  other  cases  all  milk  should  be  withheld,  and  expressed-beef 
juice;  diluted  meat  broths,  and  egg-albumen  solution  must  be  used. 
Louis  Starr  says:  "At  eight  or  ten  months  from  two  to  four  fluid 
ounces  of  thin  mutton  or  chicken  broth  free  from  grease  may  be 
allowed  each  day  in  addition  to  the  milk ;  at  twelve  months  the  yolk 
of  a  soft-boiled  egg,  rice  and  milk,  and  carefully  mashed  potatoes 
with  gravy ;  and  at  the  end  of  the  second  year  a  small  quantity  of 
finely  minced  meat." 

Cod-liver  oil  should  be  given,  but  never  until  the  digestive  func- 
tions are  well  restored,  as  shown  by  the  character  of  the  stools,  the 
absence  of  eructation  and  flatulence,  and  a  clean  tongue.  It  is  to 
be  prescribed  pure,  or  in  one  of  the  emulsions  with  calcium  lacto- 
phosphate. 

Daily  warm  baths  and  inunctions  of  two  or  three  drachms  of 
cod-liver  oil,  or,  better,  olive  oil,  are  to  be  ordered,  with  fresh  air  in 
abundance. 

Mucous  Disease,— Chronic  Pseudo-membranous 
Gastro-enteritis. — Membranous  Enteritis. 

Pathological  Physiology. —  Mucous  disease  is  an  obstinate 
chronic  affection  in  which  large  quantities  of  thick,  ropy  mucus  are 
formed  in  the  alimentary  canal,  but  chiefly  in  the  large  intestine. 
The  disease  is  accompanied  usually  by  neurasthenia  and  disorders  of 
gastric  and  intestinal  digestion  and  absorption,  of  greater  or  less 
severity. 


CA^  DIET   IN   DISEASE. 

In  the  disease  called  membranous  enteritis  a  similar  condition  is 
present,  and  the  hypersecretion  results  in  the  formation  of  long  tube 
casts  of  fibrinous  mucus.  The  passage  of  the  casts  is  sometimes 
accompanied  by  severe  paroxysmal  pains,  and  blood  may  appear  in 
the  stools.  Although  they  may  be  separated  clinically,  the  dietetic 
treatment  of  these  two  affections  is  the  same.  Young  children  nor- 
mally secrete  more  mucus  from  the  intestines  than  do  adults,  and 
the  long  continuance  of  an  irritating  diet  of  improper  food  may 
give  rise  to  hypersecretion.  Chronic  mucous  disease  is  sometimes 
a  sequel  of  the  infectious  diseases  which  particularly  affect  children, 
notably  whooping  cough.  There  are  a  larger  number  and  variety  of 
bacteria  found  in  the  stools  than  are  usually  present,  but  this  disease 
is  not  definitely  attributable  to  the  action  of  any  one  species.  The 
disease  is  also  sometimes  associated  with  intestinal  worms. 

Symptoms. — The  appetite  is  very  irregular.  It  may  be  exag- 
gerated early  in  the  disease,  and  fail  completely  later  on.  The  food 
does  not  nourish  the  child,  absorption  being  prevented  by  the  mucus, 
and  it  causes  flatulency  and  discomfort.  Emaciation  is  progressive 
and  extreme.  Some  of  the  stools  consist  wholly  of  mucus,  fatty 
epithelial  cells,  and  granular  detritus,  while  others  contain  parti- 
cles of  undigested  food,  milk  curds,  meat  fibre,  etc.,  mixed  with 
mucus. 

Dietetic  Treatment. — The  only  hope  of  cure  of  this  condition 
lies  in  the  most  rigid  dietetic  treatment,  combined  with  regular 
habits,  bathing,  etc.  In  the  worst  cases  only  predigested  fluid  food 
should  be  given,  such  as  pancreatinised  milk,  meat  juice,  and  egg 
albumen.  Beef  tea,  light  broths  of  veal,  mutton,  or  chicken,  con- 
somm/,  or  milk  punch  may  be  allowed. 

Sometimes  it  is  necessary  to  give  no  food  by  the  stomach  for  six 
or  eight  hours,  and  then  commence  to  feed  very  slowly,  giving  tea- 
spoonful  doses  at  fifteen-minute  intervals.  If  the  child  has  been 
living  for  long  upon  milk  alone,  and  the  stools  show  fat  and  undi- 
gested curds,  it  is  best  to  make  a  radical  change  and  proscribe  it  en- 
tirely. Jacobi  gives  instead  a  mixture  containing  five  ounces  of  bar- 
ley water,  one  to  two  drachms  of  brandy  or  whisky,  the  white  of  an 
egg,  and  a  little  salt  and  cane  sugar.  Dose,  a  teaspoonful  every  five 
or  fifteen  minutes.  This  is  a  fairly  palatable  mixture.  It  is  con- 
sidered best  to  withhold  all  farinaceous  and  saccharine  articles  until 
some  sign  of  improvement  appears. 

For  milder  or  convalescing  cases  in  children  the  following  diet, 
prescribed  by  Eustace  Smith,  is  recommended  : 

Breakfast,  8  A.  M. — Fresh  milk,  three  quarters  of  a  pint,  with 
twenty  drops  of  saccharated  solution  of  lime.  A  thin  slice  of  toast 
with  fresh  butter,  an  egg,  soft-cooked  or  poached. 

Dinner,   12  M. — A  lean  broiled  mutton  chop,  well-boiled  cauli- 


THE   ALIMENTARY   CANAL. 


543 


flower  or  French  beans,  toast.  A  half  to  a  wineglassful  of  sherry- 
diluted  with  twice  as  much  water. 

Tea,  4  p.  m. — The  same  as  breakfast. 

Supper,  7  p.  m. — A  breakfastcupful  of  beef  tea  (a  pound  to  the 
pint),  dry  toast. 

Edwards  prescribes  the  dietary  of  the  London  Northeastern 
Hospital  for  Children  (See  Hospital  Dietaries,  page  763). 

Dysentery. 

During  an  attack  of  acute  dysentery  the  patient  should  be  kept 
absolutely  quiet  in  bed,  and  should  not  be  allowed  to  rise  for  the 
movement  of  the  bowels,  making  use  of  a  bedpan  instead.  Through- 
out the  active  stage  the  diet  must  be  strictly  confined  to  easily  di- 
gestible food,  and  in  most  cases  it  is  wisest  to  give  only  predigested 
fluid  articles.  Peptonised  or  pancreatinised  milk,  or  boiled  milk, 
pressed-meat  juice,  whey,  or  raw  egg  albumen  beaten  with  sherry 
and  flavoured  with  nutmeg  are  recommended.  Many  patients  do 
best  upon  a  diet  of  raw  scraped  beef  or  meat  balls  (page  97). 

In  cases  of  acute  dysentery,  and  especially  in  the  amoebic  form, 
the  loss  of  strength,  anaemia,  and  emaciation  progress  very  rapidly. 

The  strength  must  be  supported  by  vigorous  stimulation,  for 
which  brandy  is  preferable  to  whisky.  An  ounce  an  hour,  or  for  a 
time  every  half  hour,  may  be  necessary  to  tide  the  patient  over  the 
emergency,  lest  heart  failure  ensue  before  the  symptoms  can  be  con- 
trolled. 

During  convalescence  the  diet  must  be  very  cautiously  increased, 
and  confined  to  food  which  is  promptly  and  completely  digested, 
leaving  but  little  residue.  For  this  purpose  animal  food  should  be 
chiefly  eaten,  while  fish,  tender  beefsteak,  roast  beef,  boiled  or  broiled 
chicken,  eggs,  custard,  blancmange,  dry  toast,  junket,  well-boiled 
rice,  or  wine  jelly,  may  be  given.  All  fruits  and  vegetables  must  be 
forbidden,  and  butter  and  cream  should  be  taken  sparingly. 

If  the  disease  occurs  in  infancy,  the  child,  if  possible,  should  be 
fed  at  the  breast.  Otherwise  all  milk  and  water  given  should  be 
sterilised  or  Pasteurised.  Beef  tea  and  mutton  broth  may  be  allowed 
in  moderation,  and  special  care  should  be  observed  not  to  overfeed. 
Pepsin  has  recently  been  recommended  for  use  in  solution  as  a 
lavement  for  the  lower  bowel  in  dysentery,  apparently  for  the  pur- 
pose of  dissolving  mucus  and  cleansing  the  ulcerated  surfaces.  This 
treatment  is  irrational,  for,  unless  acid  be  used  also,  the  pepsin  has  no 
solvent  action  in  the  alkaline  contents  of  the  large  intestine  (only 
the  caecum  has  an  acid  reaction).  If  acid  were  added  it  would  irri- 
tate the  ulcers.     Pancreatin  and  soda  would  be  better. 


37 


r^  DIET   IN   DISEASE. 


CHRONIC   DYSENTERY. 

Chronic  dysentery  is  often  best  treated  by  an  exclusive  milk 
diet  of  from  two  and  a  half  to  three  quarts  a  day,  with  rest  in  bed 
or  on  the  lounge.  In  other  cases  rare  steak  or  roast  beef  or  chicken 
and  egg  albumen  may  be  allowed,  with  dry  toast,  Zwieback,  or 
crackers.  The  milk  and  meat  diet  may  be  advantageously  com- 
bined. 

In  Osier's  opinion,  if  there  is  much  ulceration  of  the  colon  meat 
is  not  well  borne,  and  it  is  better  to  keep  the  patient  upon  a  diet 
which  will  give  but  little  residue,  such  as  boiled  or  peptonised  milk. 

The  stools  must  be  examined  every  day  or  two  to  ascertain  the 
presence  of  undigested  fragments  of  milk  curds  or  meat,  oil  globules, 
mucus,  blood,  etc.  If  improvement  does  not  occur,  the  patient  may 
be  put  upon  a  diet  of  egg  albumen  with  beef  juice,  or  some  of  the 
preparations  of  beef  meal  (page  98)  or  peptonoids,  with  pancreatin- 
ised  milk.  Return  to  solid  diet  must  be  very  gradual,  and  may  be 
conducted  on  the  lines  directed  for  convalescence  from  typhoid  fever 
(page  406). 

Acute  Intestinal  Obstruction. 

In  acute  intestinal  obstruction  absolutely  nothing  should  be 
given  by  the  mouth.  If  any  food  be  taken  it  decomposes,  and  even 
drink  may  excite  severe  vomiting.  The  patient  may  be  nourished 
for  days  by  the  rectum,  and  thirst  can  be  relieved  by  injection  of  a 
pint  of  lukewarm  water  with  a  teaspoonful  of  salt  into  the  rectum. 
If  the  latter  is  irritable  a  smaller  quantity  should  be  employed,  and 
more  frequently  given.  Another  method  of  relieving  thirst  is  to  in- 
ject a  pint  or  two  of  warm,  sterilised  salt  solution  of  the  above 
strength  into  the  cellular  tissue  beneath  the  skin,  after  the  manner 
of  the  hypodermoclysis  recommended  in  cholera  (page  422),  If  ne- 
cessary, half  an  ounce  or  more  of  whisky  is  to  be  given  from  time 
to  time  hypodermically,  weakened  by  two  or  three  times  the  quan- 
tity of  salt  solution.  If  all  these  injections  are  sterilised  and  in- 
serted deeply  they  are  much  less  painful  than  if  inserted  immediately 
beneath  the  skin. 

If  the  obstruction  is  overcome  without  operation,  the  diet  should 
be  very  slowly  increased,  giving  only  fluid  nourishment  by  the  mouth 
for  two  or  three  days,  or  until  all  symptoms  have  subsided. 

The  fluid  food  should  consist  of  beef  juice,  broths,  egg  albumen, 
and  simple  farinaceous  gruels.  Milk,  if  not  wholly  absorbed,  forms 
too  bulky  faeces. 

Cheyne  and  Brunton  (British  Medical  Journal,  September,  1894) 
have  recently  investigated  anew  the  subject  of  acute  intestinal  ob- 
struction, reaching  the  conclusion  that  the  symptoms  of  profound 


THE   ALIMENTARY   CANAL. 


545 


collapse,  thready  pulse,  etc.,  depend  not  upon  the  local  condition  of 
obstruction,  but  upon  sapraemic  intoxication  from  toxines  produced 
by  decomposition  of  retained  food. 

This  statement  is  corroborated  by  the  prompt  relief  which  some- 
times succeeds  emptying  the  bowel  after  removal  of  the  obstruction 
and  the  use  of  lavage  and  irrigation  with  warm  water  (io6°  F.). 

Roehrig  finds  that  intestinal  obstruction  increases  the  biliary  se- 
cretion. 

Chronic  Constipation. 

Physiologfy. — The  periodic  daily  evacuations  of  the  bowels  are 
determined  by  peristaltic  contractions  of  the  musculaf  wall  of  the 
intestines  excited  by  their  contents.  The  thick  fluid  condition  of 
the  food  (chyme)  which  enters  the  small  intestine  from  the  stomach 
is  gradually  altered  by  absorption  of  water  and  soluble  ingredients 
in  the  small  intestine.  This  process  is  accomplished  by  rhythmical 
vermicular  contractions  of  the  intestinal  wall  which  are  reflex  in 
character  and  stimulated  in  different  degrees  by  the  bi^k  and  chem- 
ical combination  of  the  food  and  by  the  various  digestive  secretions, 
namely,  the  intestinal  and  pancreatic  juices  and,  especially,  the  bile. 
The  peristalsis  is  more  active  in  the  small  than  in  the  ffcrge  intestine, 
for  it  has  the  triple  function  of  (i)  mixing  the  food  and  digestive 
fluids ;  (2)  bringing  the  whole  mass  into  contact  with  a  large  surface 
for  absorption  ;  and  (3)  propelling  the  residue  towards  the  large  in- 
testine. ^ 

Simultaneously  the  local  blood  current  is  increased.  The  vess 
and  lymphatics  in  the  intestinal  wall  and  mesentery  become  grea 
distended  by  absorption  of  food  products.  The  increase  in  volu 
and  flow  of  the  blood  also  stimulates  peristaltic  contractions. 

Towards  the  lower  end  of  the  small  intestine  the  food  is  found 
diminished  in  volume  by  absorption,  and  the  mass  is  consequently 
somewhat  thicker.  The  ileo-caecal  valve  is  periodically  relaxed  by 
reflex  mechanism,  and  the  peristalsis  of  the  small  intestine  propels 
the  food  onward  into  the  large  intestine,  wh^re  further  absorption 
takes  place,  and  the  residue  is  more  slowly  moved  towaids  the  sig- 
moid flexure.  Here  it  remains  and  accumulates  until  a  certain  bulk 
is  gathered,  which  by  pressure  or  distention  excites  the  reflex  mech- 
anism of  defecation.  This  mechanism  employs  a  large  number  of 
muscles,  and  hence  the  need  of  a  controlling  nerve  centre,  which 
is  found  in  the  lumbar  region  of  the  spinal  cord. 

As  a  general  proposition,  it  may  be  stated  that  constipation,  when 
not  due  to  intestinal  obstruction,  is  dependent  upon  lack  of  peri- 
stalsis, as  diarrhoea  is  due  to  excessive  peristalsis. 

Many  persons  are  wholly  ignorant  of  what  constitutes  a  normal 
stool.  The  custom  of  using  patent  water  closets  often  prevents 
them  from  seeing  the  stool,  and  they  are  unable  to  correctly  esti- 


-^  DIET    IN   DISEASE. 

mate  its  amount  or  character.  A  little  accumulation  of  residue  left 
over  each  day  will  presently  cause  very  uncomfortable  constipation. 
The  normal  stool  should  weigh  about  five  or  five  and  a  half  ounces, 
of  which  only  one  and  a  half  ounce  is  solid  matter.  It  should  con- 
stitute a  sausage-shaped  mass,  in  all  about  six  inches  in  length. 

Pathological  Physiolog^y. — Constipation  may  result  from  one 
or  more  of  the  following  causes,  which  are  related  to  diet:  i.  Insuf- 
ficient quantity  of  solid  food.  2.  Too  highly  nutritious  or  concen- 
trated food.  3.  Insufficient  fluid.  4.  Astringent  food  and  drinks. 
5.  Indigestible  food.  6.  Lack  of  digestive  fluids.  7.  Irregularity  in 
diet,  8.  Obstruction  from  overeating.  9.  Lack  of  peristalsis.  10. 
Lack  of  exercise. 

1.  Insufficient  food  is  one  of  the  most  common  causes  of  consti- 
pation. In  prolonged  starvation  the  bowels  cease  to  move  entirely. 
Persons  who  eat  but  sparingly  have  too  little  bulk  of  food  to  excite 
the  normal  peristaltic  motion  of  the  intestines,  and  the  waste  products 
accumulate  irt'consequence. 

2.  Too  highly  nutritious  or  concentrated  food,  such  as  richly 
seasoned  meats,  milk,  meat  extracts,  peptonised  fluids,  etc.,  when 
almost  compl#ely  absorbed,  leave  insufficient  residue  of  waste  mat- 
ter. Peristalsis  is  therefore  either  not  excited  or  the  contracting 
intestinal  wall  has  insufficient  bulk  of  material  to  seize  upon  and 
propel. 

^,  Insufficient  fluid  often  causes  constipation,  and  for  three  rea- 
M:  (i)  The  chyme  is  not  kept  liquid  enough  to  be  thoroughly 
fcgled  with  the  digestive  juices.  (2)  The  intestinal  walls  become 
too  dry  and  friction  over  the  hardened  faecal  masses  is  increased, 
making  it  difficult  to  propel  them.  (3)  There  is  less  fluid  absorbed 
by  the  blood,  and  consequently  the  digestive  juices  and  intestinal 
mucus  are  reduced  in  amount  and  altered  in  quality. 

4.  Astringent  food  or  drinks,  such  as  tea,  brandy,  or  claret,  con- 
stipate by  checking  the  mucous  and  other  secretions,  thereby  increas- 
ing friction  within  the  intestinal  wall. 

5.  Indigestible  food  may  be  so  hard  and  bulky  as  to  be  imper- 
fectly acted  upon  by  peristalsis  and  incompletely  mingled  with  the 
digestive  juices,  or  it  may  give  rise  to  abnormal  fermentation  and 
production  of  substances  which  inhibit  absorption  and  peristalsis. 

6.  Lack  of  digestive  fluids  in  normal  proportion  or  serious  altera- 
tions in  their  composition  retard  digestion  and  lessen  peristalsis, 

7.  Irregularity  in  diet  or  in  the  intervals  of  taking  food,  eating 
too  hastily,  imperfect  mastication,  and  great  variations  in  the  quan- 
tity of  food  eaten,  all  tend  to  disorder  digestion  by  disturbing  the 
natural  rhythm  of  its  various  stages,  and  especially  the  periodicity  of 
defecation. 

8.  Obstruction  from  overeating,  particularly  in  children,  may  cause 


THE   ALIMENTARY   CANAL. 


547 


constipation  from  the  accumulation  of  larger  quantities  of  waste  mat- 
ter than  the  intestinal  muscles  have  power  to  propel. 

9.  Lack  of  peristalsis  occurs  through  enfeebled  intestinal  muscles 
or  imperfect  nerve  stimulation. 

10.  Lack  of  exercise  fails  to  stimulate  the  circulation,  both  gen- 
eral and  local,  and  to  secure  the  abundant  oxygen  supply  needed  for 
complete  oxidation  of  the  food.  It  also  fails  to  stimulate  peristalsis 
by  the  natural  movements  of  the  body,  especially  of  the  abdominal 
muscles,  and  by  increasing  the  flow  of  bile. 

Constipation  is  not  infrequently  a  constitutional  habit  or  family 
peculiarity,  running  through  several  generations.  It  is  said  to  occur 
more  often  in  persons  of  dark  complexions,  but  this  statement  is 
open  to  question.  It  is  provoked  by  sedentary  habits  and  neglect  of 
the  calls  of  Nature,  and  it  is  the  usual  accompaniment  of  impoverished 
conditions  of  the  blood  and  malnutrition,  and  especialy  anaemia, 
neurasthenia,  hysteria,  and  chronic  diseases  of  the  liver  and  stomach. 
It  is  also  frequently  present  in  connection  with  acute  fevers,  and  the 
habit  of  the  perpetual  consumption  of  drugs  of  many  varieties  may 
occasion  it. 

Weakness  of  the  muscles  of  the  intestinal  and  abdominal  wall  are 
common  factors  in  the  production  of  constipation.  This  symptom  is 
therefore  present  in  obesity,  overdistention  of  the  abdominal  wall 
during  pregnancy,  and  in  atony  of  the  large  intestine  and  chronic 
diseases  of  its  mucous  membrane.  It  is  also  produced  by  obstruc- 
tion from  the  pressure  of  tumours,  accumulation  of  scybalae  from 
impaction  of  foreign  bodies  in  the  bowel,  stricture,  and  localised 
atony  of  the  sigmoid  flexure. 

Symptoms. — In  all  common  cases  the  symptoms  accompanying 
constipation  are  debility  and  lassitude,  while  more  or  less  mental  de- 
pression is  present  in  persons  of  nervous  or  hypocondriacal  tempera- 
ment. When  it  occurs  in  the  course  of  chronic  insanity  it  increases 
languor,  moroseness,  and  irritability  of  temper,  and  not  seldom  ex- 
cites acute  and  violent  symptoms.  As  a  result  of  the  accumulation 
of  waste  matter  in  the  lower  bowel,  internal  misplacements  may  oc- 
casionally result,  or,  if  they  already  exist,  they  may  be  increased. 
Sacral  neuralgia  is  sometimes  produced,  and  hemorrhoids  from  con- 
gestion of  the  rectal  veins  may  occur.  Occasionally  constipation 
may  result  from  malformations  of  the  intestine — adhesions  which 
bind  loops  and  coils  of  the  intestine  in  abnormal  positions  and  inter- 
fere with  peristaltic  movement.  The  impacted  faeces  accumulate  in 
the  colon  and  are  found  chiefly  in  the  sigmoid  flexure,  but  they  may 
also  form  large  tumours  in  the  hepatic  or  splenic  flexure,  or  even  in 
the  right  inguinal  region.  In  aged  persons  sacculi  of  the  colon 
may  become  permanently  distended,  and  scybalas  become  calcified 
as  enteroliths.     A  channel  is  sometimes  bored  through  the  impacted 


548 


DIET   IN   DISEASE. 


masses  of  faecal  material,  and  the  long-continued  constipation  will 
give  rise  to  diarrhoea.  The  faecal  mass  acts  as  a  local  irritant,  and 
diarrhceal  stools  pass  through  the  channel. 

Chronic  constipation  may  sometimes  give  rise  to  acute  attacks  of 
localised  pain  and  considerable  fever  (104°  F.).  These  attacks  may 
simulate  appendicitis,  localised  peritonitis,  or  other  acute  abdominal 
diseases. 

Dietetic  Treatment. — Before  ordering  the  diet  for  chronic  con- 
stipation, the  patient  must  be  minutely  interrogated  as  to  his  daily 
habits  of  life,  such  as  occupation,  hours  for  meals  and  for  exercise, 
recreation,  and  sleep,  the  kinds  of  foods  and  quantity  usually 
eaten,  the  amount  and  kinds  of  fluids  drunk,  hour  for  going  to  stool, 
the  use  of  stimulants  and  tobacco,  and  presence  of  mental  worry  or 
anxiety. 

The  principles  of  dietetic  treatment  of  chronic  constipation  are 
based  upon  supplying  digestible  food,  which  will  excite  peristalsis 
either  by  its  bulk  or  its  physical  and  chemical  properties.  Vegetable 
food  in  general,  as  distinguished  from  nitrogenous  diet,  furnishes  a 
much  larger  proportion  of  waste  matter.  Herbivorous  animals  have 
more  abundant  evacuations  than  do  carnivores. 

Following  is  a  list  of  common  foods  discussed  in  their  relation 
to  constipation  : 

Vegetables. — The  cellulose  of  starchy  foods  is  difficult  of  diges- 
tion and  of  comparatively  little  nutrient  value  for  man;  hence  it 
yields  a  considerable  quantity  of  waste  material.  This  is  true  of 
the  starch  granules  of  potatoes,  corn,  peas,  beans,  etc. 

Other  vegetables  which  leave  a  large  residue  after  digestion  are 
tomatoes,  spinach,  lettuce,  asparagus,  salsify,  cabbage,  and  celery. 
Tomatoes  and  spinach  seem  to  possess  slight  special  laxative  proper- 
ties.    Spanish  onions,  boiled,  are  laxative. 

Cereals. — The  various  cereals  used  for  bread  when  coarsely 
ground  contain  a  large  proportion  of  the  external  envelope  of  the 
grains,  which  is  more  or  less  hard  and  rough,  and  by  its  presence  in 
the  intestine  it  stimulates  peristalsis  through  mechanical  irritation. 
(See  page  120.) 

For  the  above  reasons  the  following  articles  of  diet  tend  to  over- 
come constipation :  Coarse  Graham  bread,  rye  bread,  wheatena, 
wheaten  grits,  corn  meal,  Indian  meal,  oatmeal,  brown  or  "whole- 
meal "  bread,  Boston  brown  bread. 

Molasses  and  honey  added  to  bread  are  laxative.  Gingerbread, 
especially  for  children,  is  sometimes  efficacious. 

Coffee,  beer,  cider,  and  unfermented 'grape  juice  are  somewhat 
laxative. 

Olive  oil  and  cod-liver  oil,  if  taken  at  bedtime  into  an  empty 
stomach,  are  laxatives  for  some  persons,  particularly  children. 


THE   ALIMENTARY   CANAL. 


549 


Adults  may  take  a  dessertspoonful  of  best  Lucca  oil  with  each 
meal,  eating  it  with  fresh  vegetables,  such  as  beets  or  lettuce,  or 
mixing  it  with  potatoes. 

Fruit. — Fruits  are  laxative,  either  because  they  contain  indiges- 
tible seeds,  which  act  mechanically  in  the  intestine  (e.  g.,  figs,  berries), 
or  because  the  vegetable  acids  and  salts  which  they  furnish  upon 
being  absorbed  stimulate  the  digestive  secretions  and  peristalsis. 

Fruits  eaten  with  seeds  are  laxative,  such  as  figs,  blackberries, 
strawberries,  huckleberries,  blueberries,  and  also  grapes  in  large 
amount  without  the  seeds. 

Fruits  which  possess  special  laxative  properties  through  chem- 
ical action  are  apples,  pears,  peaches,  oranges,  shaddock,  cherries, 
prunes,  plums. 

Many  fruits  act  in  both  the  above  ways,  and  raisins,  figs,  prunes, 
and  apples  leave  considerable  bulk  of  waste  matter  after  digestion. 

Fruit  is  always  more  laxative  when  eaten  between  meals  or 
some  time — say,  half  an  hour — before  breakfast.  It  then  enters  the 
intestine  more  promptly,  and  it  is  not  retarded  in  its  effect  by  the 
presence  of  other  articles  of  diet.  Its  action  is  furthered  by  drink- 
ing a  tumblerful  or  two  of  water. 

With  many  persons  constipation  may  be  prevented  by  eating  one 
or  two  oranges  or  the  juice  of  half  a  grape-fruit  before  breakfast. 
The  latter  is  very  sour,  and  considerable  sugar  is  required  to  make 
it  palatable.  This  is  a  decided  disadvantage  for  those  who  have 
flatulent  dyspepsia  or  gout.  Instead  of  sugar,  the  bitterness  may  be 
disguised  by  a  little  sherry  or  rum  poured  upon  the  cut  fruit.  A 
half  dozen  dried  figs  or  a  dozen  or  so  of  French  prunes  eaten  at  in- 
tervals during  the  day,  when  the  stomach  is  empty,  produce  a  laxa- 
tive effect.  These  fruits  in  smaller  quantities  are  very  good  for 
children. 

Cooked  Fruits. — With  many  persons  having  imperfect  diges- 
tion raw  fruits  disagree,  and  since  their  laxative  properties  are  not 
much  weakened  by  being  cooked,  it  is  better  to  eat  them  in  that  form. 
Stewed  prunes,  or  apples  either  stewed  or  baked,  are  very  easy  of 
digestion,  and  the  latter  may^ten  be  eaten  by  invalids  in  whom 
the  digestive  organs  are  very  weak.  Cooking  berries  or  other 
suitable  fruits  by  stewing  renders  them»  much  more  digestible,  and 
does  not  impair  their  nutritive  qualities.  The  principal  objection  to 
cooked  fruits  is  that  they  usually  require  so  much  sugar  to  make 
them  palatable  that  they  may  cause  flatulency.  A  little  bicarbonate 
of  sodium  will  neutralise  the  acidity,  and  saccharin  may  be  added 
instead  of  sugar. 

Canned  fruits  and  fruits  preserved  in  sirups  are  of  little  value  for 
constipation. 

A  few  fruits,  like  the  banana,  are  apt  to  cause  constipation. 


.CO  DIET   IN   DISEASE. 

Owing  to  the  prevalent  idea  that  fresh  fruit  relieves  constipation, 
patients  occasionally  eat  too  much  of  it,  with  the  result  of  producing 
dyspepsia  and  increasing  their  original  trouble. 

Water. — Copious  draughts  of  either  very  hot  or  cold  water,. two 
or  three  tumblerfuls,  should  be  taken  before  retiring  and  on  rising. 
Many  persons,  from  a  belief  that  water  drunk  with  meals  is  injurious, 
abstain  from  it  and  forget  to  take  fluid  between  meals,  and  become 
constipated  in  consequence.  If  they  happen  to  lose  water  by  free 
perspiration  also,  the  difficulty  is  enhanced.  Such  patients  should 
be  advised  to  drink  water  freely,  as  above  indicated.  It  also  aids 
digestion  to  take  a  tumblerful  of  hot  water  about  an  hour  after  a 
meal  unless  the  gastric  juice  is  feeble  in  strength  of  acidity.  The 
stomach  contents  becoming  somewhat  thickened  by  loss  of  fluid 
through  the  pyloric  orifice  or  by  direct  absorption  through  its  own 
wall,  are  better  digested  by  being  diluted  again.  The  temperature  of 
the  water  drunk  makes  but  little  difference  as  far  as  constipation  is 
concerned.  Cold  water  is  warmed  and  hot  water  is  cooled  by  the 
oesophagus,  so  that  upon  reaching  the  stomach  it  is  nearly  of  the  nor- 
mal body  temperature,  no  matter  how  much  it  differed  from  this  when 
swallowed,  provided  it  has  been  taken  slowly.  If  swallowed  in  large 
draughts  it  does  affect  the  stomach  temperature  for  a  few  moments, 
but  it  is  soon  brought  to  the  normal  body  temperature  again  (page 

When  patients  will  not  drink  enough  plain  water,  they  can  be  in- 
duced to  take  lemonade  or  water  flavoured  with  some  aromatic.  A 
few  cloves  put  in  a  tumbler  of  boiling  water  and  allowed  to  steep 
overnight  impart  their  flavour  to  the  fluid,  which  may  be  drunk  on 
rising  in  the  morning. 

Summary  of  the  most  Useful  Articles  for  Chronic  Consti- 
pation.— Abundant  water,  coarse  brown  or  bran  bread,  oatmeal, 
fresh  green  vegetables  (lettuce,  spinach,  etc.),  prunes,  figs,  apples 
(cooked  or  raw),  peaches,  berries. 

Foods  to  be  avoided. — Persons  suffering  from  habitual  consti- 
pation do  well  to  give  up  the  following  articles:  Eggs,  milk,  sweets, 
pastry,  puddings  made  of  simple  amylaceous  substances — such  as  rice, 
sago,  etc.— fried  foods,  rich  gravies,  sauces,  curry,  strong  condiments, 
pickles,  tea,  sour  or  red  wines; 

AIDS  TO  DIETETIC  TREATMENT. 
It  is  an  important  and  infallible  rule  in  cases  of  chronic  constipa- 
tion that  hygienic  as  well  as  dietetic  treatment  should  supersede  the 
use  of  medicine.  It  is  very  necessary  to  establish  a  uniform  hour 
for  going  to  stool  each  day,  and  all  efforts  at  straining  should  be 
avoided.  Exercise  in  moderation  should  be  insisted  upon,  and  should 
be  carefully  supervised.     Much  good  may  be  accomplished  by  ele- 


THE   ALIMENTARY   CANAL. 


551 


mentary  instruction  in  calisthenics,  in  which  special  attention  is  paid 
to  deep  respiratory  movements  of  the  diaphragm  and  abdominal  mus- 
cles. Of  exercise  in  the  open  air,  horseback  riding  is  by  far  the 
most  beneficial.  One  or  two  rides  a  week  are  much  better  than  none. 
Many  persons  find  improvement  from  bicycling. 

Regularity  should  be  observed  in  habits  of  life,  in  hours  of  sleep, 
and  of  meals.  Many  business  men  whose  daily  routine  of  early 
rising,  exact  hours,  and  evening  dinners  is  disturbed  on  Sundays  by 
late  breakfast  and  a  noon  dinner,  find  that  the  regular  habit  of  the 
bowels  is  interrupted  at  the  first  of  the  week,  and  in  consequence 
may  suffer  for  a  day  or  two  from  headache  and  "biliousness." 

Massage. — Massage  is  the  process  of  manipulating  the  muscles 
and  subcutaneous  cellular  tissue.  The  aim  of  the  treatment  is  to 
mechanically  compress  and  stimulate  the  structures  beneath  the 
skin,  and  it  is  to  be  distinguished  from  the  effects  of  merely  rubbing 
the  surface  of  the  body,  which  acts  through  excitation  of  the  cuta- 
neous nerves  and  circulation. 

Massage  promotes  the  movement  of  the  blood  through  the  veins 
and  of  the  lymph  in  the  lymph  spaces  and  capillaries,  and  favours 
the  removal  of  waste  products  from  the  tissues  compressed,  and  the 
increase  of  healthy  metabolism  in  the  muscles.  It  also  stimulates 
the  latter  in  a  slight  degree  to  contraction.  It  aids  the  functional 
activity  of  the  liver,  stomach,  and  bowels.  The  various  manipula- 
tions are  complex,  and  when  rightly  performed  require  the  skill  and 
experience  of  thoroughly  trained  operators.  The  chief  manipula- 
tions are  classed  as — 

1.  Percussion  by  short  quick  blows  of  the  fingers  or  small  rubber 
hammers. 

2.  Rolling  the  muscles  and  subcutaneous  tissues  beneath  the  ex- 
tremities of  the  fingers. 

3.  Kneading  with  the  fingers  and  palms  of  both  hands,  placed  one 
above  the  other,  on  the  patient's  arm  or  leg. 

Massage  of  the  abdominal  muscles  is  most  useful  for  constipation, 
and  both  percussion  or  mechanical  vibration  and  kneading  are  to  be 
used.  It  should  be  performed  in  the  direction  of  the  colon,  com- 
mencing low  down  on  the  right  side  of  the  abdomen,  ascending  to 
the  ribs,  crossing  to  the  left,  and  descending  upon  the  left  side  to 
the  sigmoid  flexure.  This  mechanical  movement  not  only  pushes 
along  the  intestinal  contents,  if  the  abdominal  wall  be  not  too  fat, 
but  it  stimulates  peristalsis  by  reflex  action.  If  possible,  it  should 
be  given  in  the  morning  before  rising,  and  at  first  daily,  for  fifteen 
or  twenty  minutes,  but  later  every  other  day. 

The  treatment  should  be  continued  for  a  month  or  more.  Obsti- 
nate cases  have  been  cured  in  this  manner,  and  the  method  is  espe- 
cially serviceable  for  very  obese  patients. 


552  I>IET   IN   DISEASE. 

Some  persons  derive  aid  from  manipulating  the  abdominal  wall 
for  themselves  while  lying  in  bed  in  the  morning. 

A  large  wooden  ball  like  a  croquet  ball  or  a  heavy  metal  ball 
weighing  four  to  six  pounds  may  be  rolled  over  the  abdomen  for  five 
or  ten  minutes  every  morning,  pressing  it  in  deeply  in  the  direction 
of  the  colon.  This  sometimes,  in  thin  subjects,  promotes  the  move- 
ment of  the  intestinal  contents. 

Medicines. — Discussion  of  the  medicinal  treatment  of  constipa- 
tion is  not  within  the  scope  of  this  work,  but  the  practice  of  contin- 
ually taking  laxatives  and  strong  cathartics  cannot  be  too  strongly 
condemned.  The  constant  daily  overexcitation  of  the  bowels  by 
such  remedies  as  aloes  produces  a  deplorable  condition  in  which  the 
bowels  refuse  to  act  at  all  without  constantly  increasing  dosage. 

The  majority  of  such  cases  can  be  cured  by  diet,  but  the  rules 
must  be  very  distinctly  laid  down,  and  the  patient  must  exercise 
patience  and  care  in  adhering  to  them.  I  have  sometimes  been  able 
to  relieve  patients  who  for  several  years  had  depended  wholly  upon 
strong  cathartic  pills  or  enemata,  by  stopping  all  medicine,  and  en- 
forcing simple  dietetic  rules,  especially  in  regard  to  drinking  abun- 
dant fluid  and  eating  laxative  and  bulky  food. 

They  often  think  that  a  daily  movement  is  absolutely  necessary, 
and  the  worry  and  nervousness  which  its  absence  occasions  in- 
creases the  difficulty. 

They  should  be  reassured,  and  told  not  to  be  concerned  if  the 
bowels  do  not  move  at  first  for  two  or  three  or  even  four  days,  and 
that  if  they  do  not  have  an  unaided  passage  in  that  interval  they  can 
certainly  be  relieved,  and  diet  and  regimen  will  succeed  in  time  if 
persistently  followed. 

In  very  obstinate  cases  when  diet  does  not  succeed  alone,  atten- 
tion to  its  regulation  will  enable  the  patient  to  obtain  the  desired 
result  with  mild  and  decreasing  doses  of  simple  saline  laxatives  such 
as  Congress,  Crab  Orchard,  or  Rubinat  water,  in  lieu  of  strong  ca- 
thartic pills,  or  patent  medicines. 

Tobacco. — Tobacco  smoking  increases  peristalsis.  Some  men 
become  constipated  when  deprived  of  their  after-breakfast  cigar. 
The  effect  of  tobacco  is  not  constant,  however,  and  by  disordering 
digestion  too  much  smoking  may  be  an  indirect  cause  of  constipa- 
tion. In  those  in  whom  it  acts  favourably  upon  the  bowels,  a  good 
cigar  is  usually  more  active  than  any  other  form  of  the  weed. 

Bathing. — A  daily  morning  cold  bath  followed  by  vigorous  fric- 
tion of  the  skin  is  also  of  great  service. 

Electricity. — Faradisation  of  the  abdominal  walls  is  frequently 
useful,  but,  owing  to  the  fact  that  the  electric  current  when  applied 
superficially  radiates  over  the  skin  without  penetrating  to  any  ex- 
tent beneath  the  surface,  it  cannot  be  expected  to  reach  the  intes- 


THE   ALIMENTARY   CANAL. 


553 


tinal  wall.  Any  benefit  derived  from  such  application  must  be  purely 
of  a  reflex  character  from  excitation  of  the  cutaneous  nerves  trans- 
mitted through  the  cord  to  the  sympathetic  nerves.  A  much  better 
method  of  applying  a  faradic  current  consists  of  introducing  one 
electrode  for  several  inches  into  the  rectum,  while  the  other  is 
moved  about  over  the  surface  of  the  abdominal  muscles.  In  this 
manner  these  muscles  may  be  made  to  contract  and  move  the  intes- 
tines to  some  extent,  and  it  is  possible  for  a  portion  of  the  current 
to  pass  through  the  sigmoid  flexure.  If  carefully  adjusted,  the  ap- 
plication of  the  current  gives  rise  to  no  pain  or  discomfort. 

Bandaging. — In  very  obese  persons,  who  are  liable  to  suffer 
from  constipation,  the  pendulous  and  relaxed  abdominal  wall  should 
be  supported  with  an  abdominal  bandage.  The  same  treatment  may 
give  comfort  when  the  wall  is  much  distended  in  child-bearing  or  by 
the  presence  of  large  abdominal  tumours  or  accumulations  of  ascitic 
or  ovarian  fluid. 

Constipation  in  Infants  and  Children. 

In  earliest  infancy  from  two  to  three,  or  even  four,  daily  evacua- 
tions from  the  bowels  are  considered  a  normal  number,  but  in  child- 
hood, as  in  adults,  one  passage  is  normal.  In  infancy  constipation 
is  exceedingly  common  on  account  of  the  milk  diet.  Bottle-fed 
babies  are  more  subject  to  it  than  sucklings.  In  infancy  the  small 
intestine  is  relatively  longer  than  in  the  adult,  the  large  intestine 
easily  becomes  distended,  the  pelvis  is  more  contracted,  and  peri- 
stalsis is  usually  less  vigorous,  owing  to  a  less  powerful  musculature 
than  obtains  in  adults. 

When  constipation  is  present  in  an  infant  at  the  breast  the  milk 
may  be  too  rich  in  casein  and  deficient  in  fat,  salts,  and  sugar.  This 
may  be  due  to  a  constipated  habit  of  the  mother,  and  laxative  foods 
should  be  given  to  her  rather  than  medicines  to  the  child.  If  the 
child  is  nursing  a  wet  nurse,  it  may  be  best  to  change  to  another  in 
perhaps  an  earlier  stage  of  lactation,  or  one  whose  milk  is  less  rich 
in  proteids. 

If  the  infant's  stools  consist  of  dry  and  brittle  scybalae  it  should 
be  given  more  water  to  drink,  or  a  little  oatmeal  water,  which 
is  laxative.  Other  simple  and  oftentimes  effectual  remedies  are 
from  half  to  a  teaspoonful  of  olive  oil,  molasses,  melted  sugar,  or 
butter. 

In  the  case  of  hand-fed  babies  when  the  milk  forms  large  and 
hard  curds,  and  when  the  proportion  of  cream  is  too  small,  the  addi- 
tion of  water  and  cream  will  often  remedy  the  evil. 

As  an  occasional,  but  not  habitual,  simple  remedy  for  constipa- 
tion in  such  cases  relief  may  be  obtained  by  making  a  mixture  of  a 
tablespoonful  of  whole-meal  gluten  flour  in  a  pint  of  water,  boil- 


554  DIET   IN    DISEASE. 

ing  for  three  hours  to  a  thick  mass,  and  adding  a  teaspoonful  of  the 
mixture,  unstrained,  to  each  feeding  bottle. 

Artificial  foods,  "  prepared  "  foods,  and  condensed  milk  are  more 
apt  to  excite  diarrhoea  than  constipation,  but  it  should  be  remem- 
bered that  they  may  cause  the  latter,  and  the  continued  use  of 
coarse  food  or  cathartics,  or  of  large  enemata,  overstimulates  the 
bowel  and  results  in  constipation. 

When  it  is  necessary  to  use  enemata  they  should  be  small,  and 
not  too  frequently  given.  From  ten  to  thirty  drops  of  glycerin  in 
two  teaspoonfuls  of  water  is  quite  sufficient  for  a  young  nursing 
infant.  The  glycerin,  by  virtue  of  its  hygroscopic  power,  abstracts 
water  from  the  rectal  mucous  membrane,  causing  hyperaemia,  which 
in  time  excites  peristalsis.  A  simple  injection  of  two  teaspoonfuls 
of  cold  water  containing  a  pinch  of  salt  is  often  successful. 

Suppositories  may  also  be  used.  They  should  be  small,  conical 
in  shape,  and  well  oiled  before  being  inserted.  They  may  be  made 
of  glycerin,  soap,  molasses  candy  (Fruitnight),  or  gluten.  The  for- 
mer is  the  best. 

For  older  children,  from  three  years  up,  some  one  or  more  of  the 
following  articles  should  be  included  in  the  menu.  By  this  means  it 
will  be  possible  to  do  without  castor  oil,  senna,  rhubarb,  strong  ene- 
mata, and  other  remedies  which  are  constantly  abused. 

Foods  recommended. — Oatmeal,  corn  bread,  cracked  wheat, 
porridge,  wheaten  bread  made  of  unbolted  flour,  bran  bread  soaked 
in  warm  milk  (Earle),  gingerbread,  bread  and  molasses  (not  sirup), 
brown  bread  and  honey,  stewed  prunes,  baked  apples,  figs,  olive 
oil  and  olives,  cod-liver  oil,  fresh  green  vegetables,  orange  juice, 
peaches,  and  whey. 

The  French  make  excellent  purgative  biscuits  for  children, 
and  a  child  eight  or  ten  years  old  may  be  given  occasionally  a 
little  tropical  fruit  laxative  or  Tamar  Indien.  A  pinch  of  dry  salt 
followed  by  a  little  water  sometimes  improves  the  action  of  the 
bowels. 

Foods  forbidden. — Certain  foods  should  be  absolutely  forbid- 
den to  older  children,  such  are  cheese,  dry  fruits  (except  figs  and 
prunes),  fruits  having  small  seeds,  spices,  pickles,  nuts,  raisins, 
dried,  salted,  or  preserved  foods  of  all  kinds,  canned  corn,  sweets, 
candies,  cakes,  and  excess  of  farinaceous  foods.  All  articles  likely 
to  produce  flatulent  dyspepsia  must  be  avoided.  Children  on  a 
mixed  diet  do  well  to  avoid  starchy  foods  and  take  more  broths  and 
soups.     Variety  in  the  diet  is  desirable. 

Children  should  be  trained  to  go  to  stool  at  regular  hours,  and 
should  be  early  taught  the  evil  consequence  of  neglect  to  respond 
to  the  calls  of  Nature.  School-teachers  should  not  detain  them  at 
their  lessons  when  they  are  inclined  to  seek  the  closet.    Water-closets 


THE   AILMENTARY   CANAL. 


555 


or  privies  are  often  dark,  cold,  and  otherwise  disagreeable,  so  that 
children  dread  going  to  them. 

Abdominal  massage  is  very  helpful  in  overcoming  chronic  con- 
stipation in  young  children.  It  may  be  performed  two  or  three 
times  a  day  for  five  minutes.  The  movements  should  be  made  with 
the  fingers  of  a  warm,  dry  hand,  which  move  the  integument  and 
abdominal  wall  over  the  intestine.  The  treatment  must  be  very 
gentle,  and  if  the  muscular  wall  is  tense,  it  may  be  conducted  while 
the  infant  is  nursing  or  feeding,  as  suggested  by  Fruitnight. 

Hemorrhoids. 

Hemorrhoids  usually  complicate  cirrhosis  of  the  liver  sooner  or 
later,  but  they  also  result  from  chronic  constipation  and  other  causes. 
The  dietetic  treatment  is  substantially  that  of  chronic  constipation 
(page  548).  Much  depends  upon  preventing  the  stools  from  becom- 
ing hard  or  bulky.  Large  quantities  of  coarse  vegetables  and  cereals 
should  therefore  be  avoided  as  well  as  milk.  Alcohol  is  injurious, 
especially  in  the  cirrhotic  cases.  Fresh  fruits  and  abundant  fluids 
are  serviceable  in  uncomplicated  cases.  Regularity  in  meals  and  in 
time  of  going  to  stool  should  be  enjoined,  with  abundant  outdoor 
exercise.     Straining  at  stool  must  be  avoided. 

Appendicitis. 

Causation. — Appendicitis  is  mainly  interesting  from  the  dietetic 
standpoint  on  account  of  the  possible  causative  relation  of  certain 
food  residues.  In  about  one  third  of  the  cases  faecal  concretions  are 
found  in  the  appendix,  and  in  one  thirteenth  foreign  bodies  have 
been  discovered.  It  is  a  popular  belief  that  the  disease  is  often  es- 
tablished by  the  presence  in  the  intestine  of  grape  seeds  or  skins, 
lemon,  orange,  or  mustard  seeds,  cherry  pits,  bits  of  chicken  bone  or 
clam  shell,  etc.,  but  such  is  not  the  case.  Substances  of  this  nature 
are  no  doubt  often  swallowed,  but  they  seldom  make  their  way  to 
the  appendix  or  do  any  harm  ;  and  it  is  now  known  that  the  disease, 
while  it  may  exceptionally  be  produced  by  such  irritants,  is  commonly 
caused  in  other  ways,  and  is  often  of  bacterial  origin.  I  have  known 
of  one  fatal  case  resulting  from  eating  a  large  number  of  soft-shell 
crabs,  but  such  accidents  are  very  rare.  On  the  other  hand,  as 
pointed  out  by  McNutt,  both  overeating  and  overdrinking  may  indi- 
rectly cause  appendicitis  as  well  as  the  consumption  of  too  highly 
seasoned  foods,  for  these  factors  provoke  catarrh  of  the  intestine, 
distending  the  bowel  with  faeces  and  g^as,  and  making  it  easy  for  the 
catarrhal  process  or  for  bacteria  of  various  sorts  to  enter  the  appen- 
dix and  set  up  local  inflammation  there.  The  recurrent  cases  are 
more  apt  to  be  Accited  directly  by  overeating  and  improper  food. 


556 


DIET   IN    DISEASE. 


Dietetic  Treatment. — The  dietetic  treatment  of  appendicitis 
which  has  not  yet  passed  into  the  surgeon's  hands  should  consist  in 
giving  only  such  food  as  will  be  thoroughly  absorbed,  leaving  as 
little  residue  as  possible  to  irritate  the  lower  bowel  and  excite  peri- 
stalsis. Until  the  outcome  of  the  attack  is  decided  it  is  best  to  put 
the  patient  upon  a  fluid  diet,  consisting  chiefly  of  nutritive  broths. 
Beaten  eggs  may  be  allowed,  and  a  moderate  quantity  of  pancre- 
atinised  milk,  whey,  or  buttermilk.  Cocoa  may  be  given,  and  strained 
gruels  of  rice  or  barley. 

In  recurrent  cases  the  patient  should  be  cautioned  to  eat  moder- 
ately and  avoid  all  coarse  or  hard  food,  such  as  grits,  coarse  oatmeal, 
tough  meats,  fibrous  vegetables,  the  skin  of  fruits  or  potatoes — in 
short,  everything  likely  to  overload  the  intestine  with  accumulated 
waste. 

The  operative  cases  should  have  the  diet  recommended  after 
laparotomy.  Usually  the  digestive  organs  require  almost  absolute 
rest  for  twenty-four  hours  after  the  operation,  and  hot  water  may  be 
sipped.  No  food  at  all  should  be  given  for  fully  six  hours  before 
operation. 

Acute  Peritonitis. 

Acute  peritonitis,  if  due  to  causes  within  the  alimentary  canal, 
demands  absolute  rest  of  the  stomach  and  intestines,  and  this  is  se- 
cured by  giving  all  nourishment,  stimulants,  and  medicines  in  the 
form  of  nutrient  enemata  (page  375).  Any  food  in  the  stomach  is 
likely  to  excite  vomiting  and  aggravate  the  pain  and  other  symptoms. 

The  patient  usually  has  disgust  for  all  food  to  such  a  degree  that 
he  dreads  taking  anything  into  the  stomach  which  is  likely  to  excite 
emesis.  The  disease  is,  moreover,  a  very  serious  one,  and  the  utmost 
care  should  be  given  to  maintenance  of  the  strength  by  the  use  of 
predigested  fluid  food. 

In  other  cases  a  very  little  fluid  nourishment  may  be  cautiously 
administered  per  os,  such  as  peptonised  milk,  light  gruels  of  pearl 
barley  or  arrowroot,  plain  meat  juice  squeezed  from  a  fresh  steak,  or 
one  of  the  forms  of  peptonised  meat  or  e.gg  albumen  in  sherry 
should  be  tried.  Only  one  or  two  teaspoonfuls  should  be  given  once 
in  fifteen  minutes  or  half  an  hour,  and  every  effort  must  be  made  to 
prevent  the  occurrence  of  vomiting  or  meteorism.  Twelve  or  fifteen 
ounces /^r  <//.?»/ of  predigested  food  given  by  the  mouth  is  all  that 
should  be  prescribed  in  such  cases.  The  resumption  of  a  full  diet 
should  be  extremely  gradual,  occupying  several  weeks. 

It  is  well  to  avoid  the  use  of  aerated  waters  of  all  kinds  on  ac- 
count of  their  tendency  to  increase  meteorism  and  render  the  patient 
still  more  uncomfortable.  Some  patients  are  willing  to  take  these 
waters  after  the  gas  has  escaped,  but  under  these  circumstances  they 
offer  no  special  advantage  over  ordinary  water,  excepting  that  some, 


LIVER   DISEASES   IN   GENERAL.  z^j^y 

such  as  Vichy,  are  more  diuretic.  Alcoholic  stimulation  is  usually 
required  in  severe  cases,  and  if  the  stomach  is  intolerant  it  should  be 
given  in  the  form  of  dry  champagne  or  dilute  whisky  or  brandy. 
The  latter  may  be  added  to  rectal  enemata. 

The  reader  is  referred  to  the  section  upon  the  diet  for  convales- 
cent typhoid-fever  patients  (page  406)  for  hints  as  to  selection  of  a 
menu  for  convalescents  from  peritonitis. 

Chronic  Peritonitis. 

In  chronic  peritonitis  the  outcome  of  chronic  intestinal  catarrh, 
or  other  disease,  plainly  cooked  animal  food  agrees  best.  Starches 
and  sugars,  from  their  tendency  to  ferment  and  dilate  the  bowels 
with  gas,  should  be  avoided.  Broiled  tender  chop,  steak,  chicken,  or 
white  meat  of  fish  may  be  given.  Eggs,  milk,  and  cream  are  permit- 
ted when  they  do  not  cause  dyspepsia.  Bread  should  be  eaten  spar- 
ingly, and  must  always  be  stale  or  toasted.  Zwieback  and  crackers 
are  given  for  variety.  AU_food  should  be  eaten  very  slowly  and  in 
very  moderate  quantities  at  a  time. 


DIET  IN  LIVER  DISEASES  IN  GENERAL. 

BlUOUSNESS. 

Symptoms. — "  Biliousness "  is  an  inaccurate  but  very  con- 
venient term  employed  to  express  functional  disorder  of  the  liver, 
usually  accompanied  by  an  oversecretion  of  bile,  which  is  often 
vomited.  The  condition  is  characterised  by  headache,  nausea, 
vomiting,  constipation,  a  furred  tongue,  anorexia,  offensive  breath, 
malaise,  and,  if  it  continues,  by  a  sallow,  yellowish,  or  pasty  com- 
plexion. 

Causation. — The  most  common  cause  of  biliousness  is  eating 
too  much  food  or  tod  rich  or  badly  cooked  food. 

Sir  H.  Thompson,  speaking  of  the  habit  of  overeating,  says: 
"  The  surplus  fund  of  nutrient  material  unused  is  stored  up  in 
some  form.  When  a  certain  amount  has  been  thus  disposed  of — the 
capacity  for  storage  varying  greatly  in  different  persons — an  unde- 
sirable balance  remains  against  the  feeder,  and  in  young  people  is 
mostly  rectified  by  a  'bilious  attack.'  This  relieves  the  system  for 
a  month  or  six  weeks,  when  the  process  may  be  repeated." 

"  In  functional  derangements  of  the  liver  much  more  perma- 
nent benefit  is  to  be  expected  from  careful  regulation  of  the  ingesta 
than  from  physic"  (Murchison). 

Continued  disregard  of  the  warnings  of  bilious  attacks  is  liable 
to  lead  in  time  to  more  serious  trouble,  such  as  habitual  lithaemia 
or  oxaluria,  and  in  some  cases  gout.      It   is   possible,  although  it 


558 


DIET   IN   DISEASE. 


is  not  absolutely  proved,  that  diabetes  may  be  placed  in  the  same 
category. 

Persons  spending  a  holiday  at  the  seaside,  who  breathe  more 
invigorating  air  than  that  to  which  they  are  accustomed  in  inland 
cities,  often  are  tempted  to  eat  too  much  and  exercise  but  little, 
with  the  prompt  result  of  overloading  the  liver  and  inducing  a 
bilious  attack,  for,  as  Harley  says,  the  liver  "acts  like  a  wise  horse 
when  overloaded — simply  stands  still  until  part  of  its  burden  is  re- 
moved." 

Those  who  have  a  tendency — often  hereditary — to  biliousness 
frequently  exhibit  idiosyncrasies  in  regard  to  special  articles  of  diet, 
the  eating  of  which,  even  in  moderation,  may  quickly  precipitate  an 
attack. 

A  bilious  condition  is  sometimes  induced  by  absorption  of  pto- 
maines from  food  in  the  alimentary  canal,  which  are  taken  up  in 
such  quantity  that  the  liver  fails  to  destroy  them. 

Bouchard  has  attempted  to  show  that  the  ptomaine- destroying 
function  of  the  liver  is  aided  by  glycogen,  and  is  consequently 
favoured  by  ingestion  of  starches. 

Dietetic  Treatment. — The  digestive  functions  of  the  liver  are 
so  varied  that  it  is  difficult  to  arrange  any  diet  for  either  functional 
or  organic  diseases  of  that  organ  which  meets  all  the  requirements 
of  theory,  but  clinical  experience  has  abundantly  proved  the  value 
of  certain  general  principles,  the  most  essential  of  which  is  that  the 
liver  should  be  taxed  as  little  as  possible,  and  a  non-stimulating 
diet  is  required. 

Food  in  general  after  it  has  reached  the  duodenum  acts  as  a 
stimulant  to  the  liver,  and  two  or  three  hours  after  a  full  meal  the 
bile  secretion  is  increased ;  but  there  are  a  few  foods  to  which  a 
special  stimulating  effect  has  been  attributed,  although  their  influ- 
ence, if  any,  is  slight.  These  are  chiefly  the  succulent  vegetables, 
like  tomatoes,  and  also  spinach  and  cresses.  Strong  alcohol,  condi- 
ments, such  as  pepper,  mustard,  spices,  and  especially  curry,  have 
the  same  effect,  and  should  be  avoided.  Fats  and  sugars  eaten  too 
freely  are  very  apt  to  disturb  the  action  of  the  healthy  liver,  espe- 
cially during  hot  weather. 

Coffee  and  tea  may  be  allowed  only  in  such  moderation  as  one  cup 
aday.  Alcohol  had  better  be  prohibited  entirely.  Beer,  ale,  porter, 
strong  liquors,  liqueurs,  and  all  sweet  wines,  such  as  champagne, 
sherry,  Madeira,  port,  and  Tokay,  must  be  absolutely  forbidden.  If 
necessary  as  a  tonic,  a  little  sour  red  wine  or  Rhine  wine,  hock,  or 
Moselle  may  be  used  (not  over  a  couple  of  glasses  daily),  or  much- 
diluted  whisky.  Of  all  the  organs  of  the  body,  none  is  more  often 
poisoned  and  made  cirrhotic  by  alcohol  than  the  liver,  and  the 
moral  needs  no  further  emphasis.      Many  other  chemical  stimuli, 


LIVER   DISEASES   IN   GENERAL. 


559 


such  as  opium,  derange  the  liver  functions  and  interfere  with  the 
elaboration  of  food. 

More  or  less  intestinal  dyspepsia  always  results  from  alterations 
in  the  quantity  or  composition  of  the  bile,  and  on  this  account  as 
well  the  food  must  be  carefully  selected,  and  all  sugars  and  most 
starchy  aliments  must  be  forbidden  as  well  as  fats. 

Among  the  articles  especially  prohibited  in  all  cases  of  liver  dis- 
ease are  condiments,  spices,  curries,  pickles,  sauces,  rich  soups, 
fried  food  of  every  kind,  veal,  pork,  sausages ;  salt  foods,  such  as 
corned  beef  and  salt  fish ;  crustaceans,  new  bread,  preserves,  and 
sweets  of  all  sorts ;  pastry,  puddings,  cakes  ;  all  the  heavier  starchy 
vegetables,  such  as  potatoes,  corn,  peas,  beans ;  salad  oil ;  oily  fish, 
like  salmon  and  sardines.     Only  fresh  food  should  be  given. 

In  acute  functional  derangement  of  the  liver,  whether  there  is 
imperfect  or  diminished  secretion  of  bile  or  hypersecretion,  it  is  best 
to  considerably  reduce  all  food  in  quantity.  At  first,  if  there  are 
vomiting  and  headache,  only  light  broths,  beef  tea,  and  perhaps  dry 
toast  or  a  cracker  should  be  given. 

In  acute  hepatic  disease  the  tongue  becomes  furred  and  the  ap- 
petite is  apt  to  fail.  The  latter,  in  a  manner,  keeps  guard  over  the 
liver,  for  when  that  organ  is  overloaded  or  incapacitated  to  work  a 
failing  appetite  leads  to  taking  in  less  food  until  proper  functional 
activity  is  restored.  But  there  are  many  chronic  cases  in  which  con- 
tinued absence  of  appetite  leads  the  patient  to  take  less  nourishment 
than  is  really  needed,  and  in  such  cases  it  is  not  a  reliable  guide.  It 
is  not  desirable  to  restrict  the  diet  too  closely  or  allow  it  to  become 
monotonous.  The  palate  should  rather  be  tempted  by  reasonable 
variety. 

In  regard  to  the  suggestions  given  below,  it  must  be  remembered 
that  they  are  very  general,  and  are  applicable  rather  to  the  chronic 
types  of  hepatic  disease,  although  they  will  serve  also  for  those 
afflicted  with  recurrent  or  intermittent  attacks  of  biliousness,  and 
should  be  followed  between  the  attacks.  In  very  active  disease, 
such  as  acute  congestion,  acute  yellow  atrophy,  abscess  of  the  liver, 
etc.,  obviously  the  diet  must  be  much  more  limited.  In  ordinary 
uncomplicated  bilious  attacks  induced  by  high  living,  a  day  or  two 
of  practical  siarvation  with  the  use  of  a  mercurial  cathartic  is  wholly 
curative. 

The  following  articles  can  usually  be  allowed  in  moderation  ex- 
cepting in  very  severe  cases  : 

Animal  Food. — The  white  meat  of  fish,  such  as  sole,  flounder, 
halibut,  smelt,  whitefish  ;  the  soft  part  of  oysters,  liver,  sweetbread ; 
lean  meat,  such  as  roast  beef,  broiled  beefsteak,  mutton  chops,  or 
chicken  (lean  beef  is  better  than  poultry  or  game)  ;  eggs,  milk  and 
its  preparations,  such  as  koumis3,  whey,  buttermilk,  junket,  malted 
38 


560 


DIET   IN    DISEASE. 


milk.  Many  persons  with  hepatic  disorder  insist  that  milk  always 
makes  them  bilious.  If  this  proves  to  be  true  of  natural  milk,  it 
should  be  predigested  or  given  with  sodium  bicarbonate  or  Vichy, 
or  in  one  of  the  numerous  ways  described  on  page  64. 

In  advanced  cases  of  hepatic  disease  milk  constitutes  an  excel- 
lent food,  and  may  be  used  abundantly,  provided  the  proper  form 
for  its  administration  in  a  given  case  is  determined.  Baked  custard 
and  blancmange  or  other  forms  of  gelatin  may  be  eaten. 

Vegetable  Food. — Of  fresh  green  vegetables  the  following  may  be 
eaten  :  Spinach,  asparagus,  tomato,  squash,  pumpkin,  celery,  oyster 
plant,  beet  tops,  cresses,  lettuce  (without  oil). 

Cereal  Foods, — Bread  should  be  eaten  in  small  amount.  It  must 
be  stale  or  toasted.  Zwieback  is  good,  and  dry  rusk,  not  too  sweet. 
Graham,  gluten,  or  wheaten  crackers  may  be  permitted.  Other 
starchy  foods  should  be  eaten  sparingly  ;  but  boiled  rice,  rice  pud- 
ding, sago,  and  tapioca  are  admissible. 

Fruits. — Fresh  fruit  in  season  is  wholesome,  and  useful  to  over- 
come the  tendency  to  constipation.  Grapes,  oranges,  strawberries, 
peaches,  and  roast  apples  may  be  eaten. 

Water  should  be  drunk  freely,  except  when  ascites  is  present; 
and  light  beverages,  such  as  lime  juice  in  aerated  water,  lemonade, 
or  dilute  raspberry  vinegar,  may  be  serviceable. 

Directions  for  Eating. — The  manner  of  taking  food  is  very 
important.  There  is  apt  to  be  hyperaemia  of  the  stomach  and  in- 
testines from  time  to  time,  as  a  result  of  engorgement  of  the  portal 
system,  and  catarrhal  conditions  are  easily  excited  in  these  organs 
by  food  which  is  hastily  bolted  without  thorough  mastication  or 
which  is  not  well  cooked  or  not  perfectly  fresh.  The  teeth  should 
always  be  examined  to  ascertain  if  the  patient  can  masticate  prop- 
erly. Fluids  should  not  be  drunk  with  meals.  The  patient  should 
not  eat  directly  after  violent  exercise  or  fatigue,  but  should  first  lie 
down  and  rest  for  three  quarters  of  an  hour.  If  he  suffers  from 
dyspepsia,  he  should  rest  after  meals  as  well.  In  many  cases  three 
meals  a  day  suffice,  but  they  should  be  given  at  intervals  of  about 
six  hours,  to  insure  complete  digestion  between.  In  others,  when 
considerably  enfeebled,  or  in  cases  of  hepatic  congestion  and  ad- 
vanced cirrhosis,  it  is  better  to  feed  the  patient  four  or  five  times  a 
day,  or  once  in  three  hours,  giving  a  smaller  quantity  of  food  which 
is  easily  digested.     It  is  advisable  to  take  the  principal  meal  at  noon. 

From  the  fact  that  the  bile  is  diminished  in  amount  or  altered  in 
composition,  constipation  is  the  rule,  and  proper  laxatives  should  be 
frequently  given  if  the  bowels  cannot  be  kept  in  order  by  fresh  fruit. 

Hot  water  in  an  empty  stomach  is  quickly  absorbed,  and  passes 
directly  to  the  liver  through  the  portal  vessels.  If  salts,  such  as 
Carlsbad   salt,  are  given,   they  are  absorbed  with  the  water,  and 


LIVER   DISEASES   IN   GENERAL. 


561 


Stimulate  the  liver  cells.  The  water  increases  the  portal  blood  pres- 
sure, and  thus  indirectly  the  pressure  of  the  gall  ducts,  and  favours 
the  elimination  of  bile. 

Moderate  systematic  exercise  should  be  prescribed  whenever 
possible,  and  the  best  forms  are  horseback  and  bicycle  riding.  The 
"  jouncing  "  movements  of  the  former  shake  and  compress  the  liver, 
and  stimulate  its  circulation  and  the  outflow  of  bile. 

Acute  Catarrhal  Inflammation  of  the  Gall  Ducts. — 
Angiocholitis. — Catarrhal  Jaundice. 

A  bland  or  non-stimulating  diet  must  be  given  in  the  acute  stage 
of  angiocholitis.  Vomiting  is  sometimes  present,  or  it  may  be  arti- 
ficially induced  as  part  of  the  treatment,  so  that  the  stomach  is  not 
in  a  condition  to  bear  solid  food.  Moreover,  much  food  on  entering 
the  duodenum  will  increase  the  local  inflammation  of  the  common  bile 
duct.  Diluted  or  peptonised  milk  is  to  be  given,  or  buttermilk,  whey, 
light  meat  broths,  clam  broth,  pressed-beef  juice,  egg  albumen. 

In  a  few  days,  if  pain,  tenderness,  vomiting,  and  fever  subside,  the 
diet  is  to  be  slowly  increased,  and  such  articles  may  be  added  as  milk 
toast,  bread  and  milk,  broths  and  light  soups  without  vegetables,  the 
breast  of  chicken,  oysters,  sweetbread,  meat  jellies.  Later,  eggs,  and 
boiled  or  broiled  fresh  steak  may  be  eaten.  Fat  and  butter  should 
be  avoided,  and  pains  should  be  taken  to  prevent  constipation  and 
putrescence  of  the  intestinal  contents. 

Fatty,  amylaceous,  and  saccharine  food  is  to  be  avoided,  and 
for  some  time  after  the  acute  symptoms  have  subsided  the  basis  of 
diet  should  be  whitefish,  lean  meats,  and  fresh  green  vegetables. 

Cooked  fruits,  not  too  sweet,  and  to  which  sugar  has  not  been 
added,  such  as  sour  apples,  prunes,  etc.,  can  be  eaten.  Considerable 
fluid  should  be  taken  both  as  a  diluent  and  to  promote  the  action  of 
the  kidneys  and  lessen  the  tendency  to  constipation.  Water  acidu- 
lated with  lemon  juice  or  effervescent  waters  (soda  water.  Seltzer, 
and  Apollinaris)  may  be  drunk  three  or  four  times  a  day  between 
meals. 

Coffee  and  tea  are  allowed  only  during  convalescence. 

Cirrhosis. — Ascites. 

Causation. — Cirrhosis  is  a  disease  of  the  liver  occasioned  by 
irritation  of  that  organ  by  substances  in  the  blood  derived  more  par- 
ticularly from  the  portal  system  after  direct  absorption  from  the 
intestine.  Among  those  irritants  may  be  mentioned  as  the  foremost 
excitant  alcohol,  which  produces  fully  60  per  cent  of  all  cases. 
Strong  alcoholic  stimulants  often  contain  fusel  oil  or  other  especially 
noxious  impurities.     The  prolonged   use  of  strong  condiments,  or 


562 


DIET   IN   DISEASE. 


spices,  such  as  curry  and  peppers,  may  occasion  cirrhosis,  as  also  may 
chronic  metallic  poisoning  by  arsenic,  antimony,  lead,  or  phosphorus. 
Experimentally,  coffee  and  ptomaines  have  been  made  to  excite  the 
disease  in  the  lower  animals,  but  it  is  doubtful  whether  the  latter 
agents  ever  reach  the  liver  in  man  in  sufficient  quantity  to  initiate  it. 
Cirrhosis  may  be  caused  in  other  ways,  but  the  facts  above  men- 
tioned show  its  frequent  relation  to  dietetic  errors.  As  a  result  of 
fibrous  hepatitis,  the  terminals  of  the  portal  vein  are  obstructed 
and  the  portal  venous  system  is  congested,  the  blood  being  dammed 
back  in  the  vessels  of  the  stomach,  spleen,  intestines,  and  pancreas. 
From  this  congestion  there  is  frequent  vomiting,  sometimes  of  blood, 
and  there  is  marked  interference  with  the  character  of  the  digestive 
secretions  as  well  as  the  process  of  intestinal  absorption. 

Dietetic  Treatment  of  Cirrhosis  without  Ascites.— Cirrho- 
sis without  accompanying  ascites  is  often  best  treated  by  a  milk  diet 
for  two  or  three  weeks.  Bread  and  crackers  may  be  allowed  with 
the  milk,  but  nothing  else.  Hot  water  and  aerated  waters  should  be 
drunk  in  large  quantities,  fasting,  to  "  flush  "  the  liver.  Subsequently 
a  light  diet  is  to  be  prescribed  in  accordance  with  the  suggestions 
given  for  the  treatment  of  liver  diseases  in  general  (page  558).  All 
condiments,  relishes,  sauces,  fats,  fried  food,  pastry,  and  sweets  must 
be  withheld,  as  well  as  alcohol  in  every  form.  The  skin  and  bowels 
must  be  kept  active. 

ASCITES. 

Pathological  Physiology. — A  further  important  symptom 
which  is  seldom  absent  towards  the  close  of  a  protracted  cirrhosis,  if 
the  patient  lives  long  enough,  is  ascites.  This  is  an  accumulation  of 
serum  in  the  peritoneal  cavity,  which  has  been  produced  by  the 
altered  blood  pressure  of  the  portal  system  and  the  altered  compo- 
sition of  the  blood  itself.  The  fluid  accumulates  with  considerable 
rapidity,  and  may  reach  an  enormous  quantity — sometimes  as  much 
as  twenty-four  quarts — greatly  distending  the  abdominal  walls,  float- 
ing the  viscera  out  of  position,  and  by  pressure  interfering  with  di- 
gestion and  absorption.  In  addition  the  loss  of  so  large  a  quantity 
of  fluid  from  the  blood  is  a  serious  detriment  to  nutrition,  inasmuch 
as  the  ascitic  fluid  not  only  contains  water  in  large  amount,  but 
serum  albumin,  which  may  be  present  in  .the  proportion  of  from  i  to  2 
per  cent  to  over  6  per  cent.  In  the  ascites  accompanying  cirrhosis 
the  loss  of  albumin  in  this  manner  may  be  somewhat  less  than  when 
the  serous  accumulation  is  due  to  other  causes. 

These  facts  should  be  borne  in  mind  in  relation  to  the  dietetic 
treatment  of  the  disease.  Repeated  aspiration  of  the  abdominal 
cavity  not  only  abstracts  large  quantities  of  water  from  the  system, 
but  also  abstracts  considerable  albuminous  material.  In  those  cases 
in  which  fluid  refills  the  peritoneal  cavity  promptly  after  aspiration. 


LIVER   DISEASES   IN   GENERAL.  563 

it  is  a  question  whether  the  nutrition  of  the  body  may  not  suffer  by 
drawing  off  so  much  serum  albumin.  On  the  other  hand,  when  once 
transuded,  it  is  of  no  further  service  to  the  organism  unless  it  can  be 
reabsorbed.  The  point  for  consideration  is  whether  too  frequent 
removal  of  the  ascitic  fluid  will  cause  greater  drain  on  the  blood 
than  would  be  consequent  upon  letting  it  accumulate  in  the  abdom- 
inal cavity.  Much  will  depend  upon  the  relative  pressure  within  the 
peritoneal  sac  and  the  blood  vessels,  which  will  affect  the  rate  of 
osmosis  of  albumin.  This  discussion  leads  to  the  query,  whether  it 
is  not  necessary  to  supply  the  constant  loss  of  albumin  by  an  in- 
creased allowance  of  animal  food,  and,  secondly,  to  what  extent  water 
should  be  withheld  from  the  dietary. 

Dietetic  Treatment  of  Cirrhosis  with  Ascites.— When  un- 
complicated ascites  is  present  it  is  generally  best  to  restrict  the  quan- 
tity of  fluid  ingested  and  put  the  patient  upon  a  *'  dry  diet,"  consisting 
of  bread  and  meats  chiefly.  By  simply  withholding  fluid  and  stimu- 
lating the  force  of  the  heart  and  the  action  of  the  kidneys  I  have 
sometimes  seen  large  quantities  of  fluids  disappear  from  the  abdom- 
inal cavity;  but  this  treatment  is  not  always  successful.  There  is 
more  hope  of  success  when  the  disease  occurs  in  young  persons,  or, 
as  it  sometimes  does,  in  children.  Cirrhosis  and  ascites  are  very 
apt  to  be  associated  with  renal  and  cardiac  lesions  and  gastric  ca- 
tarrh, which  make  it  much  easier  to  say  what  food  the  patient  must 
not  eat  than  what  he  can  have.  If  the  urine  is  very  scanty  it  may 
not  be  wise  to  withhold  fluids,  and  some  clinicians  of  wide  experi- 
ence believe  in  giving  fluids  in  unrestricted  amount,  holding  the  view 
that  this  will  increase  diuresis  to  such  an  extent  that  not  only  will 
all  the  fluid  drunk  be  promptly  eliminated,  but  that  the  active  kid- 
neys will  drain  more  from  the  blood,  which  will  in  time  be  replaced 
by  reabsorption  of  the  ascitic  fluid.  The  same  reasoning  is  often 
applied  to  cases  of  pleurisy,  general  anasarca,  etc.  It  seems  much 
more  rational  to  endeavour  to  promote  diuresis  when  possible  by 
medicinal  measures  than  to  add  a  large  bulk  of  fluid  to  an  already 
overbalanced  circulation. 

It  is  of  importance  in  every  case  to  measure  and  estimate  care- 
fully the  total  amount  of  fluid  ingested  both  in  beverages  and  as 
food  and  make  a  comparison  with  the  quantity  of  urine  voided,  and 
if  possible  with  the  weight  of  the  patient  and  girth  of  the  abdomen 
at  different  levels. 

If  the  fluid  diet  is  followed  by  rapid  reaccumulation  of  ascitic 
fluid  after  aspiration,  for  example,  within  a  fortnight,  it  is  desirable 
to  replace  it  by  as  much  simple  solid  nutriment  as  the  patient  can 
digest,  or  by  predigested  and  concentrated  foods.  An  outline  of  the 
appropriate  diet  for  such  cases  will  be  found  upon  page  432. 

The  "  grape  cure  "  and  "  milk  cure  "  have  been  strongly  recom- 


-^  DIET    IN   DISEASE. 

mended  in  Europe  for  the  treatment  of  cirrhosis  and  ascites.  They 
are  said  to  ameliorate  the  symptoms  and  promote  reparative  pro- 
cesses, both  acting  largely  through  diuretic  influence. 

Fatty  Liver. 

Pathological  Physiology. — The  liver  is  the  great  storehouse 
of  latent  energy  in  the  body,  which  is  accumulated  in  glycogen  and 
fat.  A  certain  proportion  of  fat  is  to  be  regarded  as  a  normal  con- 
stituent of  the  parenchyma  of  the  liver.  This  varies  considerably 
within  normal  limits,  depending  upon  the  character  of  the  food  in- 
gested and  the  degree  of  its  oxidation  in  the  liver  and  other  tissues. 
After  a  diet  consisting  largely  of  fats  and  oils  or  of  carbohydrates 
the  accumulation  of  fat  in  the  liver  is  considerable.  Lack  of  exer- 
cise and  unfavourable  hygienic  conditions,  by  retarding  oxidation 
processes,  also  promote  its  accumulation.  Persons  addicted  to  con- 
stant overeating  of  carbohydrates  are  therefore  liable  to  this  affec- 
tion. They  become  stout,  take  less  and  less  exercise,  and  the  second 
condition  favouring  fatty  infiltration  of  the  liver — namely,  lack  of 
oxidation — is  added.  Fatty  liver  is  also  caused  by  various  diseases  in 
which  the  composition  of  the  blood  is  altered  and  the  metabolism  of. 
oxidation  is  interfered  with.  Such  are  advanced  anaemia,  chronic 
alcoholism,  and  tuberculosis.  It  is  suggested  by  Fitz  that  the  fatty 
diet  often  recomended  for  the  latter  disease — consisting  of  cod-liver 
oil,  rich  milk,  butter,  cream,  etc — is  productive  of  fatty  disease  of 
the  liver. 

Dietetic  Treatment. — The  dietetic  treatment  is  indicated  by 
the  previous  considerations,  but  since  the  local  condition  is  commonly 
merely  an  accompaniment  of  more  serious  general  disease,  it  may  be 
unwise  to  advise  too  sudden  or  extreme  alterations  in  the  accustomed 
diet  of  the  patient.  In  general,  all  forms  of  sugar,  starch,  and  fat 
should  be  reduced  gradually  to  a  minimum,  and,  if  possible,  finally 
omitted  entirely,  excepting  in  tuberculous  patients  whose  general 
bodily  nutrition  is  of  more  importance  than  the  danger  of  local  fatty 
infiltration.  In  these  cases  the  object  desired  is  better  promoted  by 
increasing  oxidation  processes  by  climatic  and  hygienic  treatment 
rather  than  by  withholding  the  carbohydrates.  Malt  liquors  and 
alcoholic  drinks  in  general  must  be  forbidden.  In  other  cases,  espe- 
cially in  the  alcoholic  form,  the  diet  should  consist  of  nitrogenous 
food,  fresh  green  vegetables,  and  fresh  succulent  fruits.  The  fol- 
lowing articles  may  be  taken :  Lean  meat,  boiled  or  broiled  fresh 
fish,  lettuce,  spinach,  celery,  tomatoes,  gluten  bread,  and  toast. 

Amyloid  Liver. 

The  condition  of  amyloid  Hver  after  it  has  become  sufiiciently 
pronounced  for  diagnosis  is  usually  fatal  within   a  short  period,  and 


LIVER   DISEASES   IN   GENERAL.  565 

consequently  but  little  aid  can  be  derived  from  dietetic  treatment. 
The  diet  should  be  so  regulated  as  to  burden  the  digestive  organs  as 
little  as  possible,  and  in  advanced  cases  such  predigested  foods  as 
peptonised  meat  or  milk  ought  to  be  given.  If  the  stomach  diges- 
tion is  fairly  active,  nitrogenous  food  will  agree  better  than  the 
carbohydrates. 

Syphilis  of  the  Liver. 

In  advanced  syphilitic  hepatic  disease  non-stimulating  food  only 
is  permissible,  such,  for  example,  as  milk  and  eggs,  chicken,  beef 
or  mutton  broths,  fresh  whitefish,  oatmeal,  boiled  rice,  semolina, 
revalenta,  bread,  and  light  farinaceous  puddings — such  as  tapioca, 
sago,  blancmange,  and  custards. 

Alcohol  in  all  forms  is  prohibited. 

Abscess  of  the  Liver. 

In  hepatic  abscess  the  same  general  dietetic  treatment  is  to  be 
followed  as  that  indicated  for  syphilitic  disease  of  the  liver.  The 
aim  should  be  to  carefully  avoid  overloading  the  digestive  organs  at 
any  time,  and  to  give  assimilable  and  predigested  food  in  small 
quantities  at  frequent  intervals,  at  least  once  in  three  hours.  Animal 
broths  and  light  vegetable /«r/<?.y,  with  various  combinations  of  milk 
and  eggs,  should  form  the  staple  articles.  No  solid  foods  should  be 
given,  excepting  such  articles  as  a  little  whitefish,  as  sole  or  haddock, 
a  few  oysters,  sweetbread,  and  milk  toast. 

Fats  in  all  forms  are  forbidden.  Malt  liquors,  port,  sherry,  and 
all  forms  of  strong  alcohol  must  be  prohibited.  If  any  stimulant  is 
required,  a  little  hock.  Moselle,  or  champagne  may  be  taken,  or  very 
weak  brandy,  diluted  with  Apollinaris  or  Vichy. 

Gallstones. 

Pathological  Physiology. — Gallstones  are  formed  in  the  gall 
■bladder  or  larger  bile  ducts  by  precipitation  from  the  bileof  cholesterin, 
mixed  with  more  or  less  mucus.  Occasionally  they  contain  the  bile 
pigment  (bilirubin)  or  calcium  carbonate.  Cholesterin  is  an  alcoholic 
substance  which  may  be  extracted  in  varying  amount  from  the  blood 
or  nervous  tissues,  especially  the  brain,  and  from  the  bile.  It  may 
be  obtained  in  flat,  rhombic,  colourless  crystals.  Somewhat  rarely 
it  is  excreted  in  the  urine.  It  also  exists  in  the  waste  matter  con- 
tained in  the  lower  bowel.  Cholesterin  is  maintained  in  solution  in 
the  bile  by  alkaline  salts,  the  sodium  and  potassium  taurocholateand 
glycocholate.  Calcium  unites  with  the  latter  substances,  forming  new 
compounds  with  the  biliary  acids  which  are  insoluble  salts  that  no 
longer  keep  cholesterin  in  solution.  When  organic  acids  exist  in 
excess  in  the  tissues  calcium  is  liberated,  and  on  reaching  the  liver 
produces  the  above  reaction. 


566 


DIET   IN   DISEASE. 


An  excessive  accumulation  of  cholesterin  in  the  system  will  re- 
sult in  its  precipitation  from  the  bile,  and  this  occurs  when  for  any 
reason  the  bile  has  long  been  retained  in  the  gall  bladder,  where  it 
has  been  concentrated  by  reabsorption  of  some  of  its  fluid  ingre- 
dients. The  precipitation  of  cholesterin  is  favoured  by  the  presence 
of  a  pre-existing  hepatic  stone  or  any  foreign  body  in  the  gall  blad- 
der, such  as  an  intestinal  parasite,  or  its  ovum,  or  thickened  mucus. 
Some  bone  diseases,  such  as  osteomalacia,  favour  the  formation  of 
these  calculi  by  liberating  calcium  salts  from  the  bones. 

Gallstones  are  oftenest  present  in  advanced  life  and  among  those 
who  adopt  sedentary  habits  which  lead  to  accumulation  of  bile  in  the 
bladder.  On  the  latter  account  they  are  more  common  among 
females,  and  their  occurrence  is  often  related  to  excesses  of  the 
table,  in  regard  to  both  food  and  drink. 

The  formation  of  gallstones,  in  the  opinion  of  Frerichs,  is  aided 
by  too  long  intervals  between  meals,  which  allow  of  the  accumulation 
of  bile  in  the  bladder. 

All  diseases  of  nutrition,  such  as  long-continued  dyspepsia, 
chronic  rheumatism  and  gout,  diabetes,  and  obesity,  may  be  accom- 
panied by  the  formation  of  biliary  calculi. 

Among  other  explanations  given  for  the  formation  of  gallstones 
is  an  excessive  proportion  of  fat  in  the  diet,  although  cholesterin  is 
not  true  fat,  but  is  really  an  alcohol  allied  to  fats  in  some  of  its 
properties. 

Harley,  who  has  given  more  careful  attention  than  any  other 
writer  to  the  prevention  of  a  return  of  gallstones  by  dietetic  treat- 
ment, called  attention  to  their  greater  prevalence  in  cold  latitudes 
than  elsewhere,  and  attributed  this  fact  to  the  influence  of  certain 
foods,  especially  meat  fat  and  suet.  He  wrote  :  "  Starchy  puddings 
and  fat  bacon  cause  more  gallstones  in  this  country  [England],  I 
believe,  than  all  the  other  kinds  of  food  put  together." 

The  hydrocarbons  are  more  completely  consumed  in  early  years 
than  after  middle  life,  and  hence  the  greater  prevalence  of  gallstones 
in  the  latter  period,  as  above  mentioned. 

Bauer  believes  that  "  the  formation  of  gallstones  may  often  be 
referred  to  a  faulty  diet,  for  an  excessive  consumption  of  meat  or 
free  indulgence  in  fat  and  in  spirits  would  probably  favour  their 
formation." 

Since  cholesterin  constitutes  an  ingredient  of  nerve  tissue,  it  is 
believed  by  some  that  the  exhaustion  of  the  nervous  system  may 
produce  it  in  excess  as  a  form  of  waste  matter.  An  enfeebled  nerv- 
ous system  checks  the  activity  of  tissue  metabolism,  but  it  is  not 
yet  definitely  proved  that  cholesterin  represents  nerve  waste. 

Less  often  gallstones  are  composed  of  pigment  or  of  calcium 
carbonate,  or   of   various   mixtures   of   these  substances   with   one 


LIVER   DISEASES   IN   GENERAL. 


567 


another  or  with  mucus.  Individual  stones  sometimes  attain  the  size 
of  a  small  egg,  and  they  may  cause  suppuration  and  the  formation 
of  a  fistula  from  the  gall  bladder  which  opens  into  some  other  ab- 
dominal organ,  or  externally. 

In  many  cases  the  stones  exist  in  considerable  number  and  size 
without  giving  rise  to  any  symptoms  or  discomfort,  but  the  smaller- 
sized  stones  are  apt  occasionally  to  find  their  way  into  the  common 
bile  duct,  and  their  passage  provokes  intense  agonising  local  pain, 
known  as  biliary  colic. 

Dietetic  Treatment. — From  the  above  account  of  the  manner 
of  formation  of  bile  stones  it  is  evident  that  patients  who  have  once 
suffered  from  biliary  colic  or  other  symptoms  of  the  presence  of 
concretions  should  exercise  care  in  their  diet  and  habits  of  life,  in 
order  to  prevent  the  further  formation  of  stones,  and,  if  possible,  to 
aid  in  dissolving  those  already  present.  The  diet  must  be  regulated 
with  the  object  of  lessening  the  production  of  cholesterin  and  of 
diluting  the  bile.  Animal  food  may  in  itself  contain  cholesterin,  and 
should  therefore  be  taken  very  sparingly.  A  diet  of  concentrated 
animal  food,  by  diminishing  the  alkalinity  of  the  fluids  of  the  body, 
favours  the  deposition  of  cholesterin  from  the  bile,  although  this 
ingredient  may  not  be  present  in  abnormal  amount  in  such  food. 
Patients  should  be  cautioned  against  excessive  indulgence  in  any 
particular  article  of  food,  all  richly  cooked  food  must  be  given  up, 
and  if  they  are  in  the  habit  of  eating  nitrogenous  food  in  excess,  a 
larger  proportion  of  fresh  vegetables  or  farinaceous  food  should  be 
substituted. 

Calves'  brains  and  the  viscera  of  animals  used  as  food  in  general, . 
and  particularly  the  liver,  should  be  wholly  interdicted. 

Sugars  and  fats  must  be  forbidden  in  every  variety. 

Some  vegetables,  such  as  peas  and  carrots,  are  believed  to  con- 
tain material  which  closely  resembles  cholesterin.  Carrots,  more- 
over, are  sweet,  and  sweet  vegetables  and  fruits  should  be  avoided, 
and  also  egg  yolks,  on  account  of  the  fat  they  contain. 

Fresh  green  vegetables  and  acid  fruits  which,  by  virtue  of  their 
alkaline  salts  and  organic  acids,  easily  combine  in  the  blood  with 
alkaline  bases  should  make  the  basis  of  the  diet.  The  potassium 
salts  which  are  contained  in  potatoes  and  other  vegetables  in  abun- 
dant quantity  are  believed  to  be  serviceable,  because  they  retard  the 
liberation  of  calcium,  which,  it  has  been  shown,  precipitates  choles- 
terin. Bread  and  well-cooked  cereals  and  fresh  fish,  except  salmon 
and  mackerel,  may  be  eaten.  Chicken  or  lean  beef  may  be  allowed, 
but  all  meat  should  be  taken  sparingly  and  not  oftener  than  once 
a  day. 

For  the  purpose  of  diluting  the  blood  and,  through  it,  the  bile, 
large  quantities  of  fluid  should  be  ingested,  but  it  is  best  to  avoid 


568 


DIET   IN    DISEASE. 


aerated  waters  and  mineral  waters  which  contain  salts  of  lime.  A 
tumblerful  of  hot  water  should  be  drunk  at  night,  and  another  on 
rising  in  the  morning.  Champagne  and  other  beverages  which  hold 
much  carbonic-acid  gas  in  solution  must  be  avoided,  as  must  malt. 
liquors.  Coffee,  tea,  and  claret  may  be  drunk  in  moderation.  If 
the  case  is  one  in  which  considerable  gastric  catarrh  or  dilatation  of 
the  stomach  is  present,  it  is  inadvisable  to  give  much  fluid  by  the 
mouth,  and  sometimes  the  desired  result  may  be  obtained  by  inject- 
ing salt  water  through  a  long  flexible  rubber  tube  into  the  colon. 
Intestinal  irrigation  as  well  as  active  purgation  favours  removal 
of  the  bile  and  prevents  its  accumulation  in  the  gall  bladder. 
Prout  gives  one  or  two  drachms  of  sodium  phosphate  or  sulphate 
daily  to  prevent  concentration  of  the  bile.  For  purgation  the 
Carlsbad  Sprudel  salts  and  Saratoga  salts  are  valuable.  In  women 
tight  lacing  should  be  forbidden,  and  the  habit  of  sitting  long 
in  cramped  positions  which  interfere  with  free  hepatic  circulation. 

Large  doses  of  olive  oil,  several  ounces  at  a  time,  have  been 
recommended  for  use  during  the  passage  of  a  gallstone,  with  the 
idea  apparently  of  in  some  mysterious  way  lubricating  the  channels 
through  which  the  stone  is  carried.  But  the  oil,  if  absorbed,  is  taken 
up  by  the  lacteals  and  emptied  into  the  thoracic  duct  without  going 
anywhere  near  the  liver  or  bile  passages,  so  that  such  an  explana- 
tion of  its  use  is  absurd.  The  foreign  bodies  which  it  is  claimed 
appear  in  the  stools  after  giving  oil  in  this  manner  have  proved  to- 
be  not  stones,  but  inspissated  masses  of  oil. 

PANCREATIC  DISEASES. 

Disease  of  the  pancreas  is  usually  impossible  to  diagnosticate 
with  accuracy  until  it  is  far  advanced,  and  but  little  can  be  ex- 
pected from  dietetic  treatment.  Since  the  pancreatic  juice  is  on 
every  account  the  most  important  of  all  the  digestive  fluids,  being  a 
universal  digestive  agent  for  all  foods,  and  the  most  vigorous  one, 
its  absence  or  deterioration  results  promptly  in  emaciation,  which 
becomes  extreme.  When  the  presence  of  disease  of  this  gland,  such 
as  a  cyst,  is  established,  it  is  best  to  withhold  all  fats  and  carbo- 
hydrates from  the  diet.  They  are  not  digested  in  the  stomach,  and 
when  the  pancreatic  juice  fails,  they  merely  ferment  in  the  small 
intestine  and  do  positive  harm.  Milk,  pancreatinised  meat  prepara- 
tions, beef  peptonoids,  and  egg  albumen,  with  alcoholic  stimulants, 
must  constitute  the  chief  reliance  for  nourishment. 

It  is  of  interest  to  note  that  the  continued  presence  of  fat  or  oil 
in  the  stools  is  regarded  as  a  strong  diagnostic  point  in  favour  of  the 
absence  of  pancreatic  fluid.  As  a  positive  test  this  may  have  some 
value,  but  not  as  a  negative  one,  for  if  bile  is  present  in  normal 


THE   NERVOUS   SYSTEM, 


569 


quantity  the  fat  of  food  may  still  be  emulsified  and,  to  some  extent, 
absorbed.  In  a  half  dozen  cases  of  undoubted  pancreatic  cyst  in 
which  the  diagnosis  was  established  by  aspiration  or  autopsy,  I  have 
known  doses  of  several  ounces  of  olive  oil  administered  for  diagnos- 
tic purpose  to  give  no  residue  in  the  stools.  The  absence  of  fat  in 
the  faeces  does  not  therefore  necessarily  exclude  pancreatic  disease. 


DIET    IN    DISEASES   OF   THE   NERVOUS   SYSTEM. 

Neuralgia. — Gastralgia. — Enteralgia. 

Causation. — Neuralgia  is  a  term  applied  to  a  variety  of  nerve 
pains  which  may  be  associated  with  organic  lesions  of  various  struc- 
tures which  irritate  the  peripheral  nerves,  or  which  may  be  purely 
functional  and  temporary  excitations  of  the  nerve  trunks  or  their 
end  organs.  Lesions  involving  the  nerves  themselves  are  not  de- 
scribed as  neuralgias.  The  irritability  and  conductivity  of  nerve 
fibres  is  so  dependent  upon  nutrition  that  debility  resulting  from 
imprudent  living  and  improper  or  insufficient  food  would  naturally 
be  expected  to  rank  among  the  chief  predisposing  causes  of  this  af- 
fection. 

Persons  undergoing  severe  mental  worry  or  strain,  physical 
fatigue,  prolonged  exposure  to  cold,  prolonged  lactation,  etc.,  are  apt 
to  suffer  from  indigestion  or  malassimilation  of  their  food,  and  the 
one  condition  reacts  upon  the  other  in  altering  the  tone  of  the 
nervous  system. 

Moreover,  many  diseases  which  may  be  called  dietetic  in  that 
they  are  so  closely  associated  with  or  influenced  by  dietetic  errors 
(acting  eventually  through  the  composition  of  the  blood)  are  very 
commonly  accompanied  by  neuralgic  pains.  Such  are  gout,  rheu- 
matism, lithsemia,  rheumatoid  arthritis,  diabetes,  and  chronic  alco- 
holism. To  benefit  the  diseased  condition  by  appropriate  diet,  among 
other  means,  is  to  cure  the  neuralgia. 

Neuralgic  pains  are  often  connected  immediately  with  the  digest- 
ive tract,  especially  in  cases  of  neurasthenia  and  hysteria  among 
women,  and  are  excited  by  irritating  foods  or  by  fermentative  pro- 
cesses. 

Dietetic  Treatment. — The  dietetic  treatment  of  neuralgia  is 
based  upon  certain  general  principles  which  may  be  observed  where- 
ever  they  do  not  conflict  with  the  special  disease  of  which  the  pain 
may  be  merely  an  incidental  symptom.  This  treatment  is  too  apt  to 
be  overlooked  while  attention  is  wholly  given  to  devising  new  reme- 
dies for  the  immediate,  though  often  merely  temporary,  relief  of  the 
pain. 

It  is  of  the  utmost  importance  to  early  ascertain  the  cause  of 


C70  I^IET   IN   DISEASE. 

the  pain  and  learn  whether  it  be  not  due  to  one  of  the  conditions 
above  mentioned,  which  may  be  found  to  exist  in  a  latent  form. 
Careful  examination  of  the  urine  should  in  all  cases  be  made  to 
ascertain  the  possible  presence  of  the  uric-acid  diathesis,  of  sugar,  of 
phosphaturia,  etc. 

Since  a  majority  of  cases  are  accompanied  by  general  debility 
and  occur  in  anaemic,  constipated  women  who  take  little  outdoor 
exercise,  the  blood,  also,  should  be  examined  for  anaemia.  A  nutri- 
tious and  ample  diet  should  then  be  prescribed,  accompanied  by 
moderate  exercise  and  abundant  fresh  air,  to  insure  more  perfect 
oxidation. 

Anstie  says  correctly  that  "  neuralgic  patients  require,  and 
greatly  benefit  by,  a  nutrition  considerably  richer  than  that  which 
is  needed  by  healthy  persons."  This  is  particularly  true  of  the  ex- 
tremes of  age. 

Fats  and  oils  are  most  serviceable,  and  under  this  heading 
cream,  Devonshire  cream,  butter,  bacon,  fat  meat,  salad  oil,  olives,- 
and  cod-liver  oil  may  be  used. 

Neuralgic  patients  usually  dislike  fats,  perhaps  on  the  general 
principle  that  people  are  most  apt  to  prefer  different  food  from  that 
which  they  most  need  for  disordered  conditions  of  the  system. 
Some  are  even  made  bilious  by  fat,  but  with  a  little  tact  and  perse- 
verance in  selecting  the  proper  kind  of  fatty  food  and  directing  the 
mode  of  taking  it  these  objections  may  be  overcome.  Patients  may 
take  more  butter  than  usual,  though  they  refuse  cream,  or  they  will 
take  cream  though  they  refuse  cod-liver  oil.  Salad  oil  and  fat  bacon 
are  not  apt  to  provoke  objection. 

In  neuralgia  due  to  general  debility  or  anaemia  without  lithiasis, 
nitrogenous  foods  are  indicated  in  addition  to  the  fats  above  men- 
tioned, and  good  roast  beef,  beefsteak  or  chops,  eggs,  milk  with 
bread  and  butter,  light  starchy  foods,  and  fresh  vegetables  should  be 
ordered.  Meat  should  be  eaten  two  or  even  three  times  a  day,  and 
additional  lunches  may  be  given  between  meals,  consisting  of  milk,  a 
glass  of  claret  and  a  sandwich,  a  cup  of  cocoa  and  a  biscuit,  or 
broth  thickened  with  beef  meal  or  an  egg. 

Gowers  says  that  he  has  sometimes  known  "  severe  neuralgia  to 
occur  first  on  the  patient  commencing  a  purely  vegetable  diet,  to 
disappear  when  meat  was  taken,  and  recur  with  severity  on  each  of 
four  successive  attempts  to  return  to  vegetarianism." 

If  the  nervous  system  has  been  greatly  overtaxed  or  the  digest- 
ive organs  are  exceptionally  feeble,  it  may  be  advisable  to  put  the 
patient  for  a  few  days  on  a  diet  consisting  largely  of  milk,  eggnog, 
beef  broth,  and  J>ur/es,  accompanied  by  rest  and  passive  exercise 
(massage).  After  a  few  days  the  more  substantial  nitrogenous  foods 
may   be   added.     In   cases  associated  with  lithaemia  or  rheumatic 


THE   NERVOUS   SYSTEM.  57I 

diathesis,  however,  the  quantity  of  such  foods  should  be  reduced, 
and  the  special  regulations  described  under  the  heading  of  rheuma- 
tism and  lithaemia  must  be  followed. 

Coffee  and  tea  should  be  used  only  in  moderation,  and  in  bad 
cases  had  better  be  prohibited  altogether. 

Alcohol  in  restricted  dosage  benefits  many  cases,  excepting,  of 
course,  those  primarily  due  to  alcoholism.  Claret  or  Burgundy  may 
be  drunk  with  meals,  but  alcohol  should  never  be  taken  merely  to 
relieve  pain  or  otherwise  than  as  a  food,  for  there  is  danger  of  be- 
coming too  much  addicted  to  its  use. 

Substances  to  be  especially  forbidden  are  pastry,  sweets,  and 
confectionery  of  all  kinds,  griddle  cakes,  condiments,  fried  food, 
and  rich,  highly  seasoned  sauces  and  foods. 

All  meats  should  be  eaten  at  regular  intervals,  and,  except  as 
directed  above,  eating  between  meals  must  be  prohibited. 

VISCERAL   NEURALGIAS. 

The  visceral  neuralgias  are  produced  in  the  sympathetic  nerves 
chiefly.  The  digestive  viscera — stomach,  intestines,  liver,  etc. — in  a 
normal  state  are  free  from  sensory  impressions,  but  their  nerves  are 
constantly  conveying  reflex  impressions,  which,  however,  are  to  be 
distinguished  from  ordinary  tactile  'sensibility.  Hypochondriasis,  by 
concentrating  mental  attention  upon  the  various  abdominal  viscera, 
undoubtedly  develops  hypersensitiveness  to  such  nerve  currents. 

The  condition  described  as  "ptomaine  poisoning"  may  excite  a 
severe  neuralgia  as  a  symptom. 

Dietetic  Treatment  of  Visceral  Neuralgias. — Neuralgias 
of  any  of  the  abdominal  viscera  are  apt  to  be  excited  by  functional 
activity  (although  they  also  may  occur  independently  of  it),  and 
hence  the  diet  should  be  made  as  simple  and  nutritious  as  possible, 
in  order  that  digestion  shall  not  be  unduly  prolonged.  If  any  one 
article  of  food  is  found  to  excite  the  paroxysms  it  should  be  aban- 
doned. It  is  often  advisable  in  severe  cases  to  limit  the  diet  for  a 
few  weeks  to  two  or  three  simple  articles  of  food,  such  as  beef, 
bread,  milk,  and  rice. 

GASTRALGIA. 

Causation. — In  neuralgia  of  the  stomach,  called  gastralgia,  or 
gastrodynia,  the  pain  is  situated  in  the  epigastrium,  penetrating  to 
the  back.  It  is  distinctly  localised  and  intense.  It  may  be  wholly 
paroxysmal,  or  there  may  be  dull  constant  aching  with  exacerbations 
of  a  moderate  lancinating  character.  It  is  usually  relieved  some- 
what by  moderate  gentle  pressure,  but  intensified  by  deep  pressure. 
Such  pain  is  not  infrequently  associated  with  anaemia,  chronic  con- 
stipation and  hysteria,  and  in  a  severe  form,  accompanied  by  violent 


--2  I>IET   IN   DISEASE. 

vomiting,  it  constitutes  the  "gastric  crisis"  of  locomotor  ataxia. 
Gastralgia  may  also  be  occasioned  by  the  continued  excessive  use  of 
stimulants,  such  as  alcohol,  strong  tea  and  coffee,  and  chewing 
tobacco,  and  by  the  inordinate  use  of  sweets.  An  excessive  forma-^ 
tion  of  hydrochloric  acid  in  the  gastric  juice  may  occasion  a  very 
painful  variety  of  gastralgia. 

Dietetic  Treatment. — In  all  cases  of  gastralgia  careful  inquiry 
must  be  made  in  regard  to  irregularities  of  diet,  and  the  relation  be- 
tween eating  and  the  occurrence  of  the  pain.  If  the  pain  is  worse 
while  the  stomach  is  empty  and  is  mitigated  by  taking  food,  it  is 
suggested  by  Gowers  that  it  is  due  to  morbid  action  of  those  nerves 
which  normally  excite  hunger.  Such  cases  should  be  treated  by 
giving  nourishment  in  frequent  small  quantities.  In  addition  to  the 
three  regular  meals  of  the  day,  which  should  be  light,  a  glass  of 
wine  or  a  cup  of  hot  bouillon  and  a  biscuit  or  two,  or  a  glass  of 
milk  punch  or  eggnog,  may  be  taken  at  ii  a.m.,  4  p.m.,  and  again 
before  retiring.  A  tumbler  of  milk  or  a  few  crackers  may  be  kept 
by  the  bedside  and  taken  in  the  middle  of  the  night  should  the  pa- 
tient be  awakened  by  the  pain.  The  pain  itself  is  an  indication  of 
impoverished  nutrition,  and  the  nervous  system  requires  rest  while 
the  tissues  need  food.  In  still  other  cases  food  intensifies  the  pain 
and  excites  immediate  emesis.  This  is  especially  true  of  the  gastric 
crises  of  locomotor  ataxia.  Here  sedatives,  such  as  bismuth,  cocaine, 
or  anodynes  must  be  given  to  relieve  the  irritation  of  the  gastric 
mucous  membrane  while  food  is  temporarily  withheld  until  the  pain 
has  subsided.  The  diet  subsequently  should  be  gradually  increased, 
commencing  with  small  quantities  of  peptonised  albuminous  food. 
In  gastralgia  the  appetite  is  very  capricious,  and  there  may  be  ex- 
cessive craving  for  certain  articles  of  diet,  such  as  pickles,  condi- 
ments, etc. 

In  all  forms  of  gastralgia  the  pain  is  aggravated  by  distention  of 
the  stomach.  If  starchy  food  tends  to  produce  flatulency  it  should  be 
avoided,  together  with  sugars  and  fats.  Tea  and  coffee  and  tobacco 
must  be  given  up.     The  bowels  should  be  kept  freely  open. 

Hnteralg^ia — i.  e.,  a  true  neuralgic  pain  in  the  intestines — is  not 
common  if  "  peristaltic  unrest  "  be  excluded.  It  does  occur,  how- 
ever, and  most  frequently  in  the  lower  rectum,  in  which  case  it  is  to 
be  relieved  by  local  treatment  rather  than  dieting. 

Hepatalgia,  or  neuralgia  of  the  liver,  is  an  indication  of  func- 
tional overwork  of  that  organ,  which  may  be  relieved  by  a  careful 
inquiry  into  the  dietetic  habits  of  the  individual  and  correction  of 
errors  in  addition  to  purgation. 

In  severe  forms  of  neuralgia  which  do  not  yield  to  dietetic  and 
medicinal  control  prompt  relief  is  often  secured  by  change  of  scene 
and  sea  bathing,  or  a  course  of  mineral  baths.     Hygienic  measures 


THE   NERVOUS   SYSTEM. 


573 


improve  functional  activity  and  promote  oxidation  and  assimilation 
by  the  tissues  of  the  products  of  digestion,  as  well  as  the  elimination 
of  waste. 

Migraine. 

Migraine,  or  "  sick  headache,"  is  a  neurosis  characterised  by  pain 
in  the  course  of  the  fifth  nerve,  often  accompanied  by  nausea,  vomit- 
ing, mental  depression,  and  local  vasomotor  disorders. 

There  are  many  causes  assigned  to  this  affection,  among  them 
heredity,  the  gouty  diathesis,  improper  food,  etc.  Some  obstinate 
cases  are  unaffected  by  diet,  but  others  are  much  benefited  by  atten- 
tion to  it,  and  it  is  always  worth  while  to  attempt  a  cure  by  it.  The 
patient  should  be  very  closely  interrogated  in  regard  to  all  the  habits 
of  diet  and  hygiene,  such  as  the  hours  for  eating,  the  kind  of  food 
eaten,  its  method  of  cooking,  bathing,  exercise,  mental  work,  hours 
and  frequency  of  the  stools,  etc.  In  this  way  only  can  possible  faults 
be  detected  and  corrected.  The  gouty  should  be  forbidden  the  use 
of  wines,  malt  liquors,  sugars,  and  starches.  The  anaemic  should  be 
ordered  more  animal  food  and  fats  and  cod-liver  oil.  The  dyspeptic 
should  abstain  from  carbohydrates.  The  neurotic  should  give  up 
tea,  coffee,  and  tobacco.  It  has  been  shown  by  Roberts  that  both 
tea  and,  to  a  lesser  extent,  coffee  may  materially  retard  starch  diges- 
tion, even  when  drunk  in  very  small  quantities.  Yet  there  are  some 
patients  who  can  ward  off  an  impending  attack  of  migraine  by  taking 
two  or  three  cups  of  strong  tea  or  black  coffee. 

Plain  cereal  foods  may  be  allowed,  such  as  wheaten  grits,  "  ger- 
mea,"  hominy,  and  oatmeal,  but  the  addition  of  milk  and  sugar  to 
them  may  cause  fermentation  and  make  them  undesirable.  In  this 
case  saccharin  may  be  substituted,  or  an  extract  of  malt. 

Fresh  green  vegetables,  such  as  asparagus,  young  peas,  French 
beans,  string  beans,  sea-kale,  and  stewed  celery  may  be  eaten,  but 
potatoes,  corn,  cabbage,  tomatoes  and  rhubarb  should  be  avoided. 

Excepting  anaemic  patients,  those  suffering  from  migraine  should 
not  eat  much  meat.  It  is  best  to  take  it  not  oftener  than  once  a  day, 
and  the  white  meat  of  poultry  and  broiled  fresh  fish  are  better  than 
much  red  meat. 

Milk  may  disagree  and  cause  headache  through  lactic-acid  fer- 
mentation, interfering  with  digestion. 

New  bread,  pastry,  richly  cooked  food,  condiments  in  excess,  shell- 
fish, crustaceans,  cheese,  sauces,  and  desserts  in  general  are  forbid- 
den. Many  of  these  foods  may  produce  ptomaines  by  putrefactive 
fermentation,  which  act  as  poisons  to  the  blood  and  nerves.  Vinegar 
and  acid  fruits  should  not  be  eaten,  especially  in  connection  with 
amylaceous  food  (Roberts). 

Obviously  no  rules  of  diet  apply  to  all  cases  of  a  disease  which 
may  originate  from  so   many  different  causes,  and  in  chronic  cases 


cy^  DIET   IN   DISEASE. 

careful  observation  and  experimentation  will  be  necessary  to  estab- 
lish the  best  course. 

Overeating,  irregular  eating,  and  late  suppers  should  be  forbid- 
den. Outdoor  exercise,  bicycling,  or  horseback  riding  should  be 
prescribed  to  aid  digestion,  and  the  bowels  should  be  kept  active  by 
eating  fruits. 

Patients  are  often  found  who,  as  a  result  of  following  every  one's 
advice,  have  gradually  cut  down  their  diet,  one  article  at  a  time, 
until  they  are  actually  suffering  from  inanition,  and  it  requires  no 
little  tact  and  firmness  to  convince  them  that  they  can  eat  anything 
at  all.  They  will  live  on  nuts  and  fruit  alone,  or  on  hot  water  and 
raw  beef,  or  follow  the  latest  dietetic  "  fad,"  whereas  they  really  need 
a  common-sense  diet  of  plain,  nutritious  food,  such  as  that  prescribed 
above  for  neuralgia  or  anaemia. 

Decayed  teeth  are  a  frequent  cause  of  facial  and  other  neuralgias, 
and  the  pain  is  often  directly  excited  through  the  food  or  liquid 
taken  being  too  hot  or  too  cold,  or  strongly  sweet  or  sour.  Many 
persons  experience  temporary  but  severe  frontal  pain  after  swallow- 
ing iced  beverages  or  ice  cream  too  rapidly.  In  some  persons  the 
site  of  the  pain  is  in  the  vault  of  the  pharynx  or  in  the  throat  itself. 
It  is  often  relieved  by  momentarily  compressing  both  carotid  arter- 
ies. Brunton  suggests  that  cold  excites  the  sympathetic  plexuses 
about  the  carotids  and  alters  their  calibre,  putting  them  into  a  state 
of  spasm.  These  forms  of  neuralgic  pain  are,  however,  usually  triv- 
ial, and  are  to  be  avoided  by  proper  care  of  the  teeth  and  regulating 
the  temperature  of  the  food. 

Neurasthenia. 

Causation. — Neurasthenia  is  a  condition  of  loss  of  tone  of  the 
nervous  system  which  is  of  a  functional  rather  than  an  organic  char- 
acter. It  is  also  called  nervous  exhaustion  or  nervous  prostration. 
Strictly  speaking,  it  is  not  a  disease,  but  rather  a  functional  derange- 
ment of  considerable  duration,  which,  however,  with  proper  care  and 
dietetic  treatment  results  usually  in  complete  recovery.  The  most 
apparent  cause  of  neurasthenia  is  overwork  of  the  nervous  system 
due  to  continued  excitement  or  strain  or  prolonged  emotional  de- 
pression and  anxiety.  It  is  far  more  apt  to  be  produced  by  overwork 
of  the  nervous  system  than  of  the  muscular  system,  although  it  may 
be  occasioned  by  the  latter.  Different  individuals  are  endowed  with 
varying  degrees  of  nerve  force,  and  the  Comdex  demands  and  great 
activity  of  highly  developed  civilisation  tempt  or  compel  many  peo- 
ple to  draw  upon  their  physiological  capital  of  energy  at  the  expense 
of  its  income,  with  the  result  of  exciting  the  entire  central  nervous 
system,  including  both  brain  and  spinal  cord,  to  an  unwonted  and 
sometimes   dangerous    degree.      For   this    reason    neurasthenia    is 


THE   NERVOUS   SYSTEM.  575 

essentially  an  affection  incident  to  the  occupations  and  customs  of 
city  life,  rare  or  comparatively  unknown  in  the  repose  of  the  coun- 
try. It  is  a  curious  but  undeniable  fact  that  there  appears  to  be 
more  or  less  fashion  in  regard  to  some  diagnoses,  in  nomenclature  at 
least,  if  not  in  the  diseases  themselves,  and  of  late  years  "nervous 
prostration  "  has  taken  rank  among  ordinary  functional  disorders. 

The  general  name  neurasthenia  includes  a  large  variety  of  nerv- 
ous symptoms,  and  while  all  of  the  physiological  processes  of  the 
body  are  more  or  less  impaired,  the  symptoms  may  predominate  in 
one  or  more  mechanisms,  as,  for  instance,  that  of  the  circulation, 
gland  secretion,  or  absorption. 

Men  who  find  themselves  in  business  straits  or  in  circumstances 
of  prolonged  anxiety  feel  that  they  are  straining  their  vital  powers, 
and  resort  to  an  increased  or  excessive  use  of  stimulants,  such  as 
alcohol,  tobacco,  coffee,  and  various  drugs,  to  excite  their  overtaxed 
mental  and  physical  powers  into  greater  activity.  By  means  of  this 
substitution  of  force,  especially  with  the  use  of  alcohol,  they  are  en- 
abled to  work  on,  and  still  further  excite  a  debilitated  nervous  system 
until  finally  the  limit  of  endurance  is  reached,  and  some  slight  addi- 
tional strain  reduces  them  to  utter  prostration.  Not  infrequently 
local  functional  disorders,  such  as  writer's  cramp,  neuralgia,  etc.,  give 
warning  that  a  general  neurasthenic  condition  is  imminent,  and  if 
this  warning  be  not  heeded  in  time,  more  serious  symptoms  inevitably 
follow. 

Neurasthenia  reacts  on  the  digestive  system,  producing  malnutri- 
tion and  a  variety  of  functional  disorders,  for  so  dependent  is  the 
whole  alimentary  canal  upon  a  normal  vigorous  blood  supply  and 
nerve  regulation  that  it  necessarily  suffers  profoundly. 

General  Treatment. — The  treatment  of  neurasthenia  is  funda- 
mentally based  upon  two  absolutely  essential  conditions :  First, 
complete  body  rest,  with  the  necessary  absence  of  the  original  ex- 
citing cause  of  the  difficulty,  which  will  enable  the  impoverished 
tissues  to  become  regenerated  and  have  the  balance  of  their  energy 
properly  retarded;  secondly,  a  nourishing  diet,  which  will  supply 
the  material  for  this  energy  and  tissue  metamorphosis.  Various 
tonics,  such  as  strychnine,  iron,  and  arsenic,  are  of  recognised  bene- 
fit to  the  nervous  system,  but  the  main  reliance  in  all  treatment 
must  be  placed  upon  rest  and  food.  The  milder  cases  may  be  re- 
lieved by  a  change  of  occupation  and  the  enforcing  of  strict  rules 
in  regard  to  the  hours  of  sleep,  the  methods  and  time  of  eating  and 
taking  exercise,  bathing,  etc.  Many  persons  with  functional  nervous 
disorder  have  no  appetite  early  in  the  day,  but  towards  evening  can 
eat  a  substantial  meal,  and  they  should  dine  late. 

Patients  who  for  years  have  been  accustomed  to  exceedingly 
active  mental  work  find  it  almost  impossible  to  endure  confinement, 
39 


5/6 


DIET   IN   DISEASE. 


absence  from  social  intercourse,  and  lack  of  occupation,  and  in  such 
cases  the  advantages  of  dietetic  treatment  may  be  enhanced  by 
cheerful  surroundings  and  diversion.  As  a  rule,  it  is  far  easier  for 
the  fatigued  or  worried  business  man  or  "  brain  worker  "  to  break 
off  completely  his  accustomed  occupation  for  a  period  of  several 
weeks  or  months,  to  be  spent  in  travel  or  at  some  foreign  spa,  than 
it  is  for  him  to  continue  his  ordinary  occupations  in  moderation,  and 
take  exercise  and  proper  food  and  sleep  in  accordance  with  the 
rules  laid  down  by  the  physician. 

In  many  cases  of  this  nature  travel  affords  a  certain  and  fairly 
prompt  relief,  but  it  has  the  disadvantage  that  it  involves  consider- 
able irregularity  in  the  hours  of  rest,  character  of  diet,  etc.,  as  well 
as  the  fact  that  many  are  deterred  from  this  means  of  cure  by  the 
expense  involved.  In  another  class  of  cases  too  active  travelling 
is  stimulating  and  fatiguing,  and  if  such  people  are  not  made  ill 
at  sea  nothing  gives  more  benefit  than  the  isolation,  invigorating 
air,  and  enforced  idleness  of  a  sea  voyage.  For  others,  in  whom 
the  digestive  system  is  but  comparatively  little  impaired,  camping  or 
living  an  outdoor  life  in  the  woods  affords  the  same  advantage. 
Whatever  journey  is  undertaken,  therefore,  should  be  in  the  direc- 
tion of  rest  and  moderate  diversion  without  the  sight-seeing  which 
is  involved  in  visiting  new  cities.  The  physician  should  not  only 
study  carefully  the  previous  habits  of  the  patient,  but  should  con- 
sult his  tastes  in  regard  to  occupations  and  amusements.  When 
this  is  done  and  his  confidence  has  been  thoroughly  gained,  it  is 
far  easier  to  have  the  rules  for  diet  which  are  prescribed  carefully 
adhered  to.  In  still  another  class  of  cases  of  neurasthenia  the 
general  nerve  ■'  breakdown  "  is  so  sudden  and  the  exhaustion  so  ex- 
-treme  that  absolute  rest  at  home  and  in  bed  is  imperative.  To 
this  class  of  cases  belong  a  large  number  of  overworked  society 
women  whose  lives  of  constant  excitement  and  mental  activity  or 
stimulation,  combined  with  the  number  of  charitable  interests  or 
other  occupations  to  which  they  give  much  energy,  wear  them  out 
in  time. 

The  most  severe  cases  of  neurasthenia  require  special  treatment, 
the  principles  of  which  are,  first,  complete  rest  for  body  and  mind; 
secondly,  systematic  feeding;  and  thirdly^massage.  This  treatment 
is  applicable  to  those  cases  in  which  the  nervous  system  is  so 
greatly  exhausted  that  the  patient  suffers  continual  depression  from 
the  least  exercise,  exertion,  or  emotional  excitement.  In  some  in- 
stances insomnia  is  a  predominant  and  serious  symptom  ;  in  others 
the  patient  is  drowsy  in  the  daytime  and  unable  to  perform  any 
concentrated  mental  labour ;  in  others  again  inanition  is  the  most 
pronounced  feature,  and  the  rapid  loss  of  weight  and  failure  of 
strength   alarms   the    patient,  or   the  body   may   even   increase   in 


THE   NERVOUS   SYSTEM. 


^5/7 


weight,  while  the  muscles  become  soft  and  so  feeble  as  scarcely  to 
support  the  frame.  Many  cases  are  complicated  with  pronounced 
hysteria,  hypochondriasis,  or  unnatural  irritability. 

One  of  the  first  requisites  in  treatment  is  to  secure  a  faithful 
and  intelligent  nurse  and  to  isolate  the  patient  from  well-meaning 
but  oversympathetic  friends  whose  constant  inquiries  and  sugges- 
tions are  apt  to  aggravate  existing  conditions  by  focusing  the 
attention  of  the  patient  upon  them.  In  general,  it  is  best  to  allow 
no  one  to  see  the  patient  excepting  the  trained  nurse,  the  physician, 
and  perhaps  some  one  trusted  member  of  the  family.  All  business 
matters  and  domestic  news  of  an  exciting  or  depressing  character 
should  be  carefully  kept  from  the  patient,  and  such  connection  as 
may  be  allowed  with  the  outside  world  should  be  only  of  a  cheer- 
ing and  encouraging  nature. 

It  is  very  important  that  the  nurse,  who  is  so  constantly  with  the 
patient,  should  be  congenial  and  possessed  of  the  requisite  tact  and 
cheerfulness  of  disposition.  Many  of  these  details  may  seem 
trivial,  but  their  importance  is  appreciated  after  experience,  which 
shows  how  easily  infringement  of  the  rules,  such  as  the  untimely 
reception  of  exciting  news  or  the  visit  of  an  untactful  friend,  may 
react  upon  the  digestive  system  and  interrupt  the  favourable  prog- 
ress of  the  case  for  several  days.  This  is  particularly  true  of  all 
hysterical  cases.  On  the  other  hand,  there  are  some  instances  in 
which  patients  with  active  minds  do  decidedly  better  if  mild, 
pleasurable  occupation  or  entertainment,  such  as  reading  aloud,  is 
provided  for  them,  which  is  carefully  limited  to  prevent  fatigue. 

It  is  necessary  to  explain  the  general  plan  of  cure  and  its 
object  to  both  patient  and  family  in  order  to  secure  their  co- 
operation, and  this  having  been  done,  the  treatment  which  has 
received  the  name  of  "  rest  cure  "  should  be  outlined  by  definite 
rules  in  a  most  careful  and  systematic  manner.  To  be  of  any  serv- 
ice, the  rest  cure  should  last  six  weeks  or  more,  and  in  severe 
cases  it  should  be  explained  that  this  treatment  by  no  means 
completes  the  restoration  of  the  normal  nerve  functions,  but  is  to  be 
regarded  as  a  basis  for  a  further  regimen  of  exercise  and  outdoor 
life.  While  the  rules  for  diet  for  individual  cases  must  be  distinctly 
laid  down,  and  conscientiously  adhered  to,  there  is  scarcely  any 
other  variety  of  disease  in  which  the  physician  is  called  upon  to  ex- 
ercise more  tact  and  discretion,  and  the  success  of  the  treatment 
will  depend  very  largely  upon  the  extent  to  which  he  adapts  its 
provisions  to  the  needs  of  individual  cases.  It  is  comparatively 
easy  to  prescribe  definite  regulations  for  the  treatment  of  neuras- 
thenia, but  practically  there  is  no  case  which  does  not  present  in- 
dividual peculiarities  which  require  special  consideration. 


578 


DIET  IN    DISEASE. 


THE   "REST  CURE." 

At  the  commencement  of  treatment  in  severe  cases  the  patient 
must  lie  absolutely  quiet  in  bed  and  not  be  even  allowed  to  raise 
the  arms  or  head  to  take  food.  After  a  week  or  ten  days  of  such 
enforced  and  absolute  rest,  the  patient  may  gradually  be  allowed  to 
sit  up  and  feed  herself,  but  usually  a  full  month  or  six  weeks  should 
be  spent  in  bed  with  no  further  exertion.  The  lack  of  voluntary 
exercise  must  be  supplied  by  the  tonic  effect  of  bathing  and  mas- 
sage. The  patient  should  receive  a  sponge  bath  every  morning  soon 
after  breakfast,  which  is  to  be  given  with  hot  water,  or  hot  sea 
water  if  it  can  be  obtained.  A  portion  of  the  body  only  is  to  be 
sponged  at  a  time,  and  friction  with  a  coarse  towel  should  immedi- 
ately follow.  In  some  cases  benefit  results  from  rubbing  k  piece  of 
ice  or  a  cloth  dipped  in  ice  water  over  the  skin  for  a  moment  after 
the  hot-water  sponging.  The  alternate  stimulation  of  the  cutane- 
ous nerves  by  strong  degrees  of  heat  and  cold  always  produces  a 
tonic  effect,  and  the  influence  of  the  ice  water  and  friction  is  analo- 
gous to  that  produced  by  the  Brand  system  of  cold  bathing. 

After  the  bath,  which,  if  properly  given,  may  consume  a  half  or 
three  quarters  of  an  hour,  the  patient  must  be  allowed  to  rest,  and 
at  noon  or  in  the  early  afternoon  massage  is  to  be  given,  at  first 
every  day,  and  later  on  alternate  days.  At  the  commencement  of  the 
case  the  massage  should  be  exceedingly  mild,  and  caution  is  required 
in  this  respect,  for  neurasthenic  patients  are  often  injured  by  the 
too  vigorous  or  prolonged  efforts  of  the  massage  operators.  For 
the  first  day  ten  or  fifteen  minutes  will  suffice,  and  if  the  effect  is 
favourable,  the  time  may  be  gradually  extended  to  an  hour.  Owing 
to  the  nature  of  the  diet,  which  at  first  is  fluid  and  composed  of 
milk,  and  from  the  lack  of  exercise  and  loss  of  tone  of  the  intes- 
tinal walls,  neurasthenic  subjects  are  uniformly  constipated,  and  the 
massage  should  be  particularly  adapted  to  remedy  this  difficulty. 

Massage  of  the  abdominal  muscles  should  be  performed  by 
gently  rubbing  and  kneading  the  abdomen,  commencing  in  the  right 
iliac  fossa  and  following  the  direcflbn  of  the  colon  upward  to  the 
free  border  of  the  ribs  across  to  the  opposite  side  and  downward 
to  the  sigmoid  flexure.  By  this  means  peristaltic  action  is  undoubt- 
edly stimulated,  and  the  contents  of  the  large  intestine  are  mechan- 
ically propelled  in  the  proper  direction. 

Dietetic  Treatment. — The  feeding  of  the  patient  must  be 
based  upon  the  principle  of  giving  all  the  nourishment  which  can 
be  assimilated.  The  stools  should  be  carefully  watched  from  day  to 
day  to  make  sure  that  the  milk  or  other  articles  of  food  are  thor- 
oughly digested.  Nourishment  should  be  given  at  brief  intervals, 
which  must  depend  somewhat  upon  the  amount  of  time  allotted  to 


THE   NERVOUS   SYSTEM. 


579 


sleep,  but  in  cases  of  great  exhaustion  patients  should  not  be  per- 
mitted to  go  more  than  four  hours  at  any  time  without  food,  and 
sleep  must  be  interrupted  for  feeding,  if  necessary.  In^ther  cases 
when  sleep  so  interrupted  is  readily  resumed,  food  may  be  given 
with  regularity  once  in  two  hours  throughout  the  day  and  night,  as 
in  typhoid  fever.  When  improvement  is  attained,  the  intervals  of 
sleep  will  naturally  be  longer,  and  it  will  be  both  unnecessary  and 
unwise  to  awaken  the  patient  for  feeding.  The  basis  of  the  diet 
in  most  cases  should  be  milk,  and  by  studying  the  taste  and  diges- 
tion of  the  patient  it  is  usually  possible  to  prepare  it  in  such 
a  manner  that  it  is  well  borne  (see  Adaptation  of  Milk  for  the  Sick, 
page  72). 

In  commencing  the  milk  diet  the  objection  of  the  patient  often 
has  to  be  overcome,  and  it  is  advisable  to  begin  slowly,  giving 
skimmed  milk  in  tablespoonful  doses  four  or  five  times  a  day  for 
two  or  three  days  until  the  patient  is  accustomed  to  it.  Other 
food  is  of  course  allowed  at  first,  but  this  is  to  be  gradually  reduced 
and  the  milk  substituted  for  it  in  increasing  quantity  until  four 
ounces  of  skimmed  milk  are  taken  every  two  hours.  It  is  finally 
given  up  to  eight  or  ten  ounces  at  the  same  intervals.  The  taste,  if 
disagreeable,  may  be  overcome  by  the  addition  of  a  little  black 
coffee  or  caramel.  If  it  produces  weight  and  epigastric  oppression 
or  causes  flatulence  and  eructations  it  is  to  be  diluted  by  one  half  or 
one  third  with  lime,  barley,  or  rice  water  or  Vichy.  One  of  the 
"prepared  foods,"  such  as  Nestle's  or  Mellin's,  may  be  added,  or  the 
milk  may  be  pancreatinised  or  temporarily  replaced  by  koumiss  or 
matzoon.  The  exclusive  milk  diet  tends  to  make  the  patient  drowsy 
and  to  allay  irritability  in  all  the  organs  of  the  body,  and  it  is 
actively  diuretic. 

The  constipation  which  the  milk  occasions  may  be  overcome  by 
a  pill  of  ox  gall  or  a  dose  of  bitter  water  in  the  morning,  or  by 
enemata  of  warm  soapsuds,  when  the  latter  do  not  produce  the  ex- 
haustion which  occasionally  follows  their  use. 

Many  patients  do  very  well  on  the  exclusive  milk  diet  for  a 
period  of  several  weeks,  and  they  may  be  fed  very  much  as  typhoid- 
fever  patients  are,  excepting  that  they  may  take  more  milk.  If 
they  can  digest  it,  two  and  a  half  or  three  quarts  a  day  should  be 
given. 

Weir  Mitchell,  who  was  the  pioneer  of  this  method  of  treatment 
in  this  country,  prescribes  an  exclusive  milk  diet  less  rigidly  than 
formerly.  After  five  or  six  days  of  such  treatment  a  chop  or  a 
poached  egg  may  be  added  at  noon.  The  next  day  bread  and 
butter  or  bread  and  milk  is  given,  besides^  for  supper,  and  then  an 
egg  or  a  little  meat  at  breakfast,  until  the  patient  is  taking  three 
good  meals  of  plain  food  daily,  but  in  addition  at  least  two  quarts 


-3o  DIET  IN  DISEASE. 

of  milk.    The  exclusive  milk  diet  is  believed  to  prepare  the  digestive 
system  for  the  assimilation  of  other  foods. 

Playf air's  Diet. 

Playfair's  diet  for  neurasthenia  is  a  good  example  of  a  milk  diet, 
soon  combined  with  other  foods,  as  follows  : 

First  Day. — Twenty-two  ounces  of  milk  in  divided  doses. 

Second  Day. — Fifty  ounces  of  milk  in  divided  doses. 

Third  Day. — Fifty  ounces  of  milk  in  divided  doses.  Massage, 
half  an  hour. 

Fourth  Day. — Fifty  ounces  of  milk  in  divided  doses  ;  ^%%,  bread 
and  butter  ;  dialysed  iron,  forty  minims  in  two  doses.  Massage, 
one  hour  and  a  half. 

Sixth  Day. — Fifty  ounces  of  milk  in  divided  doses ;  mutton  chop. 
Massage,  one  hour  and  fifty  minutes. 

Eighth  Day. — Fifty  ounces  of  milk  in  divided  doses;  mutton 
chop  ;  porridge  and  a  gill  of  cream  ;  maltine,  twice  daily.  Massage, 
three  hours;  electricity,  half  an  hour;  continued  to  end  of  treat- 
ment. The  solid  food  is  now  gradually  increased  until  such  a  diet  is 
reached  as  the  following  for  the 

Tenth  Day. — 6  a.  m.,  raw  meat  soup,  ten  ounces  ;  7  a.  m.,  a  cup  of 
black  coffee;  8  a.  m.,  a  plate  of  oatmeal  porridge,  a  gill  of  cream,  a 
boiled  egg,  three  slices  of  bread  and  butter,  and  cocoa;  11  a.m., 
milk,  ten  ounces  ;  2  p.  m.,  rump  steak,  one  half  pound  of  potatoes, 
cauliflower,  a  savoury  omelet,  milk,  ten  ounces ;  4  p.  m.,  milk,  ten 
ounces ;  three  slices  of  bread  and  butter ;  6  p.  m.,  a  cup  of  gravy 
soup ;  8  p.  M.,  a  fried  sole,  roast  mutton  (three  large  slices),  French 
beans,  potatoes,  stewed  fruit,  and  cream;  milk,  ten  ounces;  11  p.m., 
raw  meat  soup,  ten  ounces. 

Fifteenth  Day. — Three  full  meals  daily  of  fish,  meat,  vegeta- 
bles, cream,  and  fruit ;  two  quarts  of  milk  and  two  glasses  of  Bur- 
gundy. 

Twenty-second  Day. — Amount  of  food  lessened. 

Ley  den's  Diet. 

Leyden's  diet  for  neurasthenia  is  a  modified  form  of  milk  treat- 
ment which  gives  excellent  results  in  some  cases : 

At  7  A.  M.,  half  a  litre  of  milk,  slowly  sipped  in  half  an  hour,  a 
small  cup  of  coffee  with  cream,  eighty  grammes  (nearly  three  ounces) 
of  cold  meat,  a  mealy  baked  potato;  10  a.m.,  a  litre  of  milk  with 
three  biscuits  ;  12  a.  m.,  the  same  ;  i  p.  m.,  broth,  two  hundred  grammes 
(about  seven  ounces)  of  fowl,/«r/<?  of  potatoes,  green  vegetables, 
one  hundred  and  twenty  grammes  (nearly  four  ounces)  of  compote, 
and  pastry  ;  3.30,  5.30,  8,  and  9.30  p.  m.,  half  a  litre  of  milk,  mak- 
ing a  daily  consumption  of  three  litres  and  a  half  of  milk.     In  the. 


THE   NERVOUS   SYSTEM. 


58r 


after  part  of  the  day,  two  meals  each   of   eighty  grammes  (three 
ounces)  of  roast  meat  with  bread  and  three  biscuits. 

Keating  s  Diet. 

Keating's  diet  for  neurasthenia  is  adapted  to  patients  who  need 
not  be  kept  constantly  in  bed.     It  is  as  follows : 

At  6  A.  M.,  a  tumblerful  of  strong  hot  beef  tea ;  8  a.  m.,  a  half  tum- 
blerful of  iron  water,  and  breakfast  of  fruit,  steak,  coffee,  and  a 
goblet  of  milk  ;  8.30  a.  m.,  a  goblet  of  milk  with  a  dessertspoonful  of 
malt  extract,  six  grains  of  citrate  of  iron  and  quinine  ;  10  a.  m.,  elec- 
tricity ;  12  A.M.,  a  goblet  of  milk  and  malt;  2  p.m.,  dinner,  preceded 
by  a  half  tumblerful  of  iron  water  and  a  third  goblet  of  milk  and  malt ; 
6  p.  M.,  third  dose  of  iron  water.  Light  supper  of  fruits,  bread  and 
butter,  and  cream  ;  a  fourth  goblet  of  milk  and  malt;  10  p.m.,  beef 
soup,  four  ounces,  preceded  by  massage  with  cocoa  oil  for  an  hour. 

Two  quarts  of  milk  are  taken  daily,  in  addition  to  all  other  food. 
The  patient  on  this  diet  is  allowed  to  be  out  of  bed  for  four  hours 
every  day,  one  of  which  may  be  spent  in  business. 

If  milk  can  not  be  made  to  agree  with,  the  patient  in  any  form, 
meat  broths  dind  purees  and  light  farinaceous  food  may  be  prescribed. 
Eggs  may  be  given  dropped  into  bouillon  or  any  of  the  preparations 
of  tgg  albumen.  Meat  essences  and  extracts,  such  as  Liebig's  or 
Valentine's,  are  serviceable,  but  the  latter  are  so  merely  for  their 
stimulating  effect  upon  digestion.  If  the  condition  of  the  stomach 
is  good,  the  constipation  resulting  from  so  concentrated  a  diet  may 
be  overcome  by  the  use  of  oatmeal  porridge  for  breakfast,  whole- 
meal bread,  and  fresh  fruits,  such  as  the  juice  of  the  shaddock  or 
dried  or  stewed  prunes.  A  reference  to  the  receipts  given  at  the 
end  of  this  book  for  the  several  kinds  of  fluid  food  will  enable  the 
physician  to  prescribe  sufificient  variety  to  stimulate  the  appetite  of 
the  patient,  and  in  many  cases  a  slightly  different  menu  can  be  or- 
dered for  each  day  in  the  week.  Most  patients  after  a  fortnight  to 
three  weeks  of  semisolid  diet  are  able  to  digest  meat  and  other 
solid  foods.  As  an  example  of  an  excellent  typical  dietary  for  this 
stage  of  the  treatment,  the  following  is  given  by  H.  C.  Wood  : 

At  8  A.  m.,  rolls  or  toast,  cocoa,  weak  coffee  or  roasted  wheat  cof- 
fee, beefsteak,  tenderloin,  or  mutton  chop  ;  9  a,  m.,  bathing ;  1 1  a.  m., 
oatmeal  porridge  with  milk  or  else  a  half  pint  of  molasses;  12  noon, 
massage;  2  p.m.,  dinner,  bouillon  with  or  without  egg,  beefsteak, 
rice,  white  potatoes  roasted  ;  dessert  of  bread  pudding,  blancmange, 
or  similar  farinaceous  articles ;  4  p.  m.,  electricity  ;  5  p.  m.,  milk  toast ; 
9  p.  M.,  a  half  pint  of  skimnfed  milk  or  koumiss. 

Bilfinger  believes  that  a  modified  vegetable  diet  is  most  useful  in 
the  treatment  of  neurasthenia,  being  less  irritant  to  the  nervous  sys- 
tem than  a  preponderance  of  animal  food,  and  for  anaemic  subjects 


582 


DIET    IN   DISEASE. 


who  require  proteids  he  prescribes  milk  and  oatmeal  porridge  and 
preparations  of  ground  meal  of  legumes.  He  allows  chocolate  and 
cocoa  for  beverages. 

Electricity. — The  use  of  the  electric  current  is  of  service  in  pro- 
moting the  nutrition  of  the  body  during  the  period  of  absolute  resl 
from  voluntary  movement.  It  should  be  distinctly  remembered  that 
the  electric  current  itself  possesses  no  special  nutritive  value  or 
"  vitalising  "  influence,  such  as  is  often  claimed  for  it,  but  that  it 
acts  favourably  upon  the  muscular  system  by  causing  the  muscles  to 
contract,  and  in  that  way  also  quickens  the  circulation.  The  con- 
traction of  muscles  compresses  the  contents  of  their  lymphatic  ves- 
sels and  venous  radicles,  and  in  this  way  aids  circulation,  while  the 
phenomena  are  accompanied  by  metabolism  which  involves  the  ap- 
propriation of  the  ingredients  of  the  food  which  have  been  absorbed. 
The  faradic  current  is  used  exclusively  for  this  purpose.  It  may  be 
applied  to  special  groups  of  muscles  at  first,  and  subsequently  to  the 
entire  body.  Care  should  be  taken  not  to  fatigue  individual  muscles, 
and  the  current  should  be  carefully  regulated  and  applied  in  accord- 
ance with  the  condition  of  the  patient.  The  use  of  electricity  in 
relation  to  the  treatment  of  constipation  has  been  referred  to  under 
that  heading.  It  is  doubtful  whether  the  local  application  of  elec- 
tricity over  the  abdominal  wall  exercises  any  definite  influence  upon 
'the  digestive  processes  which  may  be  going  on  in  the  viscera  beneath 
the  electrodes. 

Insomnia  and  Disordered  Sleep. 

Insomnia  is  due  to  many  causes,  but  those  which  concern  die- 
tetics are  the  opposite  extremes  of  overfeeding  and  starvation  or  in-, 
anition.  Overfeeding  or  eating  improper  food  may  cause  disordered 
sleep,  nightmares,  or  temporary  insomnia  from  attacks  of  acute  in- 
digestion, dyspepsia,  or  biliousness,  but  inanition  or  malnutrition  is 
more  apt  to  cause  true  insomnia  from  exhaustion.  Neurasthenic 
subjects  whose  nerve  energy  is  insufficient  to  conduct  their  digest- 
ive and  absorptive  functions  completely  are  very  liable  to  suffer 
from  insomnia.  They  unfortunately  resort  to  hypnotic  drugs  in- 
stead of  first  trying  the  efficacy  of  dietetics. 

It  is  a  good  rule  in  such  cases  to  improve  the  nutrition  by  care- 
fully regulated  feeding  at  frequent  intervals.  In  addition  to  three 
good  meals  a  day,  the  patient  should  be  made  to  take  one  or  two 
quarts  of  milk,  with  beef  tea  and  one  or  two  ounces  of  malt  extract. 
By  gradually  increasing  the  diet  according  to  such  rules  as  those 
given  for  the  treatment  of  neurasthenia,  in  a  week  or  ten  days  the 
patient  can  often  be  made  to  reach  the  maximum  above  given,  and 
improvement  is  almost  certain  to  follow.  It  is  best  to  take  the 
heaviest  meal  of  the  day  in  the  early  afternoon  not  as  late  as  sijs 


THE   NERVOUS   SYSTEM,  583 

o'clock,  for  an  overloaded  stomach  with  indigestion  is  itself  a  cause 
of  insomnia,  but,  on  the  other  hand  going  to  bed  with  a  perfectly 
empty  stomach  is  usually  undesirable.  In  mild  cases  a  glass  of  hot 
milk,  a  couple  of  teaspoonfuls  of  meat  extract  in  hot  water,  or  a 
cup  of  good  beef  tea  and  a  biscuit,  or  a  cup  of  cocoa,  or  chicken 
broth,  or  a  light  sandwich  and  a  glass  or  two  of  beer  or  ale,  taken 
just  before  retiring,  will  serve  to  divert  the  blood  current  from  the 
brain  to  the  stomach  and  induce  cerebral  anaemia  and  sleep  with- 
out the  use  of  medicines,  stimulants,  or  "nightcaps,"  and  if  anodynes 
have  to  be  given,  a  little  food  taken  in  this  manner  increases  their 
efficacy  and  makes  a  smaller  dose  possible. 

Vertigo. 

Vertigo,  although  it  arises  from  many  causes,  may  be  occasioned 
by  digestive  disorders,  such  as  the  production  of  flatulency  and  pal- 
pitation, or  by  the  absorption  of  products  of  indigestion  which  act 
as  irritants  of  the  vascular  system.  Such  products,  for  example,  are 
developed  in  some  persons  by  eating  shellfish,  strawberries,  etc. 
(page  353).     Lack  of  sufficient  food  may  cause  it. 

The  dietetic  treatment  is  that  of  dyspepsia  (page  496).  Fats, 
sugars,  and  starches  are  forbidden,  and  alkaline  and  laxative  waters, 
such  as  Vichy,  Congress,  or  Hathorn  water,  are  of  service  to  open 
the  bowels  and  increase  the  activity  of  the  kidneys. 

Chorea. 

Mild  cases  of  chorea  require  no  special  regulation  of  diet  beyond 
that  which  is  directed  towards  the  prevention  of  flatulent  dyspep- 
sia (page  500)  and  constipation  (page  545).  In  more  pronounced 
cases  it  is  sometimes  advisable  to  put  the  patient  for  a  time  upon  a 
milk  diet.  Sweets  and  farinaceous  foods  should,  as  a  rule,  be  for- 
bidden for  fear  of  increasing  palpitation  through  exciting  flatulence. 
Other  patients  do  better  with  a  diet  of  animal  food,  consisting  of 
meat,  fish,  eggs,  and  oysters  with  bread  and  milk,  koumiss,  or  mat- 
zoon.  They  are  apt  to  be  anaemic,  and  they  should  be  encouraged 
to  take  as  much  food  as  the  digestive  organs  will  tolerate.  Cod- 
liver  oil  is  very  useful  in  these  cases. 

Epilepsy. 

Epilepsy  is  a  functional  nervous  disorder,  which  may  often  be 
considerably  improved  by  careful  attention  to  diet.  A  very  large 
proportion  of  cases  occur  in  childhood  at  a  period  when  existing 
functional  derangements  of  the  nervous  system  are  readily  aggra- 
vated by  improper  food.  Many  rhachitiq.  children  with  imperfect 
development  of  the  teeth,  feeble  digestive  organs,  and  consequent 
malnutrition   develop    epilepsy   while   teething.      Of    twenty-seven 


SH 


DIET   IN   DISEASE. 


cases  occurring  among  children  recently  analysed  by  Osier,  mord 
than  one  half  developed  before  the  fifth  year  and  more  than  three 
fourths  before  the  tenth  year.  Very  many  cases  are  closely  asso- 
ciated with  errors  in  diet  or  affections  of  the  alimentary  canal,  and 
while  such  conditions  may  not  cause  the  disease,  they  readily  precip- 
itate epileptic  seizures.  This  statement  applies  to  grand  mal  and 
petit  mal  rather  than  to  the  localised  or  partial  convulsions  known 
as  Jacksonian  epilepsy,  which  are  due  to  local  and  definite  cortical 
motor  irritation.  Of  the  varieties  of  epilepsy,  petit  mal  is  more 
favourably  influenced  by  diet  than  are  the  other  forms. 

Patients  should  have  their  eating  supervised  with  care.  They 
should  be  well  fed,  but  must  eat  only  easily  digestible  food  and  have 
their  meals  at  regular  intervals,  and  the  principal  one  must  be  in 
the  middle  of  the  day  in  order  that  digestion  at  night  may  be  com- 
pleted before  going  to  sleep.  All  food  should  be  eaten  slowly,  and 
meat,  if  given,  must  be  very  thoroughly  masticated,  and  the  stomach 
should  never  be  overloaded. 

As  a  rule,  meat  should  be  allowed  but  once  a  day.  Some  chil- 
dren with  petit  mal,  or  even  grand  mal,  improve  rapidly  on  a  strictly 
vegetarian  diet  or  on  a  bland  diet  of  which  milk,  bread  and  butter, 
and  simple  starchy  foods,  such  as  rice  pudding,  cornstarch,  Indian- 
meal  pudding,  etc.,  form  the  basis.  I  have  seen  cases  of  epilepsy 
among  young  children  in  which,  while  the  medicinal"  treatment  re- 
mained constant,  a  return  to  meat  diet  was  invariably  followed  by 
convulsions,  which  were  absent  on  a  vegetable  or  exclusive  milk 
regimen. 

As  a  rule,  adults  do  not  seem  to  be  aided  by  dieting  to  such  a 
degree  as  children ;  nevertheless,  they  do  well  to  take  but  little 
meat  and  to  be  abstemious  and  regular  in  their  habits  of  eating. 
Dr.  Mersan,  of  the  West  Riding  Asylum,  in  England,  tried  the  ex- 
periment of  putting  a  number  of  chronic  epileptics  for  some  weeks 
first  upon  a  diet  of  flesh  and  then  upon  a  vegetable  diet,  and  z'/V^ 
versa.  The  results  showed  that  their  convulsions  were  not  materi* 
ally  lessened  in  number  or  severity,  but  it  was  noticed  that  while 
their  food  consisted  largely  of  meat  their  mental  condition  was  more 
stupid. 

Gowers  allows  his  patients  meat  twice  a  day,  and  asserts  that  he 
has  seen  cases  in  which  fewer  epileptic  seizures  occurred  while  eat- 
ing flesh  than  when  abstaining  from  it.  One  patient  had  paroxysms 
only  after  eating  beef,  but  not  in  connection  with  other  varieties  of 
meat.  It  is  evident  that  no  definite  rule  should  govern  all  cases. 
It  is  worth  while  to  reduce  the  nitrogenous  food  for  a  month  or 
two,  and  if  improvement  does  not  follow,  or  nutrition  becomes  less 
active,  it  may  again  be  added  to  the  dietary. 

Dr.  Whitmore  Steele,  lately  of  the  Utica  State  Asylum,  in  speak* 


THE   NERVOUS   SYSTEM.  585 

ing  of  the  treatment  of  chronic  epilepsy  at  that  institution,  informs 
me  :  "  We  endeavour  to  reduce  the  amount  of  albuminous  foods, 
giving  a  more  liberal  and  easily  assimilated  diet  also.  Invariably 
overalimentation  in  our  epileptics  produces  attacks."  Epileptics  will 
often  gorge  themselves  with  food  and  drink  if  allowed  to  do  so. 

Some  of  the  carnivores,  as  well  as  animals  accustomed  to  a 
mixed  diet,  develop  convulsions  from  a  too  liberal  allowance  of 
meat,  if  at  the  same  time  they  are  kept  in  confinement.  In  these 
cases,  however,  the  convulsions  may  be  due  to  reflex  irritation  from 
the  stomach  or  bowels,  produced  by  large  masses  of  slowly  digested 
food,  rather  than  to  the  chemical  nature  of  the  food.  The  same 
thing  may  occur  in  young  children  who  are  allowed  to  gorge  them- 
selves with  any  hastily  eaten  bulky  diet,  and  the  resulting  convul- 
sions should  not  be  confounded  with  genuine  epileptic  seizures 
accompanied  by  loss  of  consciousness,  and  recurring  periodically. 
Some  patients  have  a  distinct  epigastric  aura  preceding  the  convul- 
sions. 

Many  are  obliged  to  take  large  doses  of  the  bromides  and  other 
medicines.  It  will  be  found  that  the  disagreeable  symptoms  of 
bromism  are  much  less  apt  to  occur  if  the  diet  be  so  regulated  as  to 
carefully  avoid  constipation  and  to  insure  the  consumption  of  abun- 
dant fluid  diluents.  Vichy  or  carbonic-acid  water  and  water  should 
be  drunk  freely  between  meals,  and  especially  after  taking  medicine, 
and  daily  thorough  evacuations  of  the  bowels  should  be  secured  by 
the  use  of  fresh  vegetables  and  fruits,  prunes,  figs,  apples,  oranges, 
etc.  Adults  should  abstain  from  agents  which  are  likely  to  over- 
stimulate  the  nervous  system,  such  as  alcohol  and  strong  tea  and 
coffee.     The  use  of  tobacco  should  also  be  interdicted. 

Beri-beri. 

Beri-beri  is  a  rare  form  of  probable  multiple  neuritis  sometimes 
imported  into  this  country  by  Chinese,  Ceylonese,  or  Japanese  pa- 
tients, who  have  acquired  it  in  their  native  countries  or  on  the  voyage. 

It  is  characterised  by  anaemia,  general  oedema,  and  more  or  less 
stiffness  and  paralysis  of  the  extremities,  with  dyspnoea  and  serous 
effusions.     Sometimes  there  are  muscular  spasms. 

Beri-beri  has  been  attributed  to  the  absence  of  fresh  animal  food 
from  the  diet,  a  sort  of  antithesis  to  the  cause  often  assigned  to 
scurvy.  It  has  more  specifically  been  attributed  to  the  excessive 
consumption  of  rice  and  adzuki  beans  to  the  exclusion  of  other  food  ; 
but  these  views  are  incorrect,  for  upon  the  authority  of  Baelz  it  is 
stated  that  the  best  fed  and  best  nourished  are  frequently  subject  to 
the  disease.  In  the  Japanese  navy,  where  the  disease  was  formerly 
not  seldom  encountered,  it  has  been  practically  exterminated  by  in- 
creasing the  nitrogenous-food  ration  and  lessening  the  carbohydrates. 


586 


DIET   IN  DISEASE. 


The  latest  view  of  the  disease  is  that  it  is  not  caused  by  bad  food, 
but  by  a  micro-organism,  and  that  bad  food  and  bad  hygiene  are 
merely  predisposing  factors. 

Locomotor  Ataxia. 

Locomotor  ataxia  is  a  disease  which  cannot  be  said  to  be  particu- 
larly influenced  by  any  system  of  dietetic  treatment,  although  it  is 
believed  by  some  writers  that  the  quantity  of  meat  ordinarily  eaten 
should  be  reduced.  As  in  many  other  forms  of  very  chronic  nervous 
disease,  a  generous  diet  is  desirable,  with  an  abundance  of  fat,  butter, 
cream,  cod-liver  oil,  etc.,  when  the  stomach  will  tolerate  it.  Strong 
liquors  should  be  forbidden,  but  light  wines,  malt  liquors,  tea,  and 
coffee  may  be  allowed  in  moderation.  A  reasonable  use  of  tobacco 
need  not  be  proscribed. 

In  those  cases  in  which  the  "  gastric  crises  "  predominate  the 
diet  must  be  restricted  for  a  few  days  when  the  crises  occur,  upon 
the  principles  established  for  the  treatment  of  gastralgia  (see  Gas- 
tralgia).  It  may  be  necessary  at  such  times  to  put  the  patient 
upon  a  simple  milk  diet. 

Other  diseases  of  the  spinal  cord  do  not  usually  demand  particu- 
lar dietetic  treatment,  but  Bauer  says  that  "  some  diseases  of  the 
spinal  cord  lead  to  an  extraordinary  falling  off  of  the  demand  for 
nutriment."  This  is  due  to  alterations  in  general  metabolism,  which 
is  further  evidenced  by  a  marked  reduction  in  temperature. 

Apoplexy. 

The  several  forms  of  cerebral  haemorrhage  may  interfere  with 
nutrition  in  a  variety  of  ways.  If  coma  is  present,  voluntary  degluti- 
tion being  suspended,  great  care  must  be  exercised  in  feeding  the 
patient.  Liquid  food  is  best  given  in  teaspoonful  doses,  and  the 
effect  of  each  spoonful  must  be  carefully  watched  to  see  that  it  is 
successfully  swallowed  before  another  is  given,  otherwise  fatal  chok- 
ing may  result  from  food  passing  over  an  insensitive  epiglottis  and 
larynx,  when  particles  of  food  may  be  drawn  into  the  lungs  and  ex- 
cite local  disease.  Concentrated  meat  extracts,  beef  peptonoids,  and 
peptonised  milk  may  be  given  in  this  manner. 

In  extreme  cases,  when  rigidity  of  the  jaw  interferes  with  feeding, 
or  when  paralysis  involves  the  mechanism  of  deglutition,  a  long, 
slender  catheter  may  be  introduced  through  the  nose  and  passed 
into  the  stomach,  through  which  fluid  nourishment  is  poured,  after 
the  manner  of  feeding  patients  suffering  from  melancholia  (see  Mel- 
ancholia, page  589). 

The  rectum  may  also  be  utilised  for  nutrient  enemata  (page  375). 
In  unilateral  facial  paralysis  without  unconsciousness  patients  may 
be  willing  and  able  to  swallow,  but  mastication  is  difficult  pr  impos- 


THE  NERVOUS  SYSTEM.  587 

sibie.  The  food  constantly  gets  into  the  buccal  cavity  behind  the 
teeth  of  the  paralysed  side,  and  the  tongue,  perhaps  also  partially 
paralysed,  dislodges  it  with  great  difficulty.  The  retfention  of  food 
is  accompanied  by  a  copious  secretion  of  saliva,  which,  dribbling 
from  the  depressed  angle  of  the  mouth,  adds  greatly  to  the  discom- 
fiture of  the  patient.  All  nourishment  should  therefore  be  given  in 
fluid  form,  or  in  such  finely  divided  state  that  it  does  not  require 
mastication,  and  can  be  readily  washed  down  with  water.  Milk, 
thick  hroths,pur/es  thickened  with  macerated  vegetables,  long-boiled 
rice,  sago,  or  barley  with  cream,  custards,  soft-cooked  eggs,  etc., 
may  be  given.  The  patient  should  be  fed  very  slowly  to  prevent 
the  food  from  running  out  of  the  mouth.  The  mouth  should  be 
frequently  cleansed  with  listerine  or  a  saturated  aqueous  solution 
of  boric  acid.  In  cases  of  hemiplegia  without  facial  paralysis  the 
patient  can  masticate  and  swallow,  but  the  mental  condition  or  loss 
of  appetite  makes  the  use  of  food  which  can  be  swallowed  with  the 
least  possible  effort  desirable.  Convalescent  hemiplegic  cases  which 
run  a  very  protracted  course  naturally  suffer  from  lack  of  exercise, 
and  almost  invariably  become  constipated.  It  is  well  in  such  in- 
stances to  recommend  simple  and  non-nitrogenous  diet,  containing 
laxative  food,  cooked  fruit,  and  coarse  cereals,  to  regulate  the 
bowels.  It  is  important  to  reduce  arterial  tension,  to  prevent,  if  pos- 
sible, a  repetition  of  the  intracranial  haemorrhage.  Large  draughts 
of  fluid  rapidly  absorbed  tend  by  adding  to  the  volume  of  the  blood, 
to  temporarily  increase  the  intravascular  pressure.  The  blood  ves- 
sels, however,  show  a  very  remarkable  ability  to  maintain  an  aver- 
age pressure  of  the  fluid  within  them,  and  the  possible  danger  from 
this  source  of  an  exclusive  fluid  diet  may  be  averted  by  increasing 
the  functional  activity  of  the  kidneys  by  diuretics  and  reducing  the 
arterial  tension  by  the  remedies  in  common  use,  such  as  chloral, 
nitroglycerin,  and  the  nitrites.  When  the  tension  is  very  high,  it 
is  well  to  give  a  non-stimulating  diet  without  much  meat,  and  milk 
should  form  the  basis  of  it. 

Alcoholic  stimulants  should  be  forbidden.  * '^ 

Acute  Insanity. — Melancholia. — Primary  Dementia. — 

Mania. 

Acute  insanity  may  result  from  overwork  or  severe  mental  strain, 
or  from  numerous  diseases.  It  overtaxes  the  vital  powers  and  causes 
wasting,  inanition,  and  exhaustion.  As  the  symptoms  may  result 
quite  suddenly,  often  within  a  few  hours  after  intense  emotional 
strain  or  excitement,  the  digestive  system  is  at  first  not  necessarily 
disturbed  to  any  considerable  extent,  although  the  appetite  may  be 
entirely  absent.  Subsequently  various  digestive  disorders  and  mal- 
nutrition may  supervene. 


■588 


DIET   IN   DISEASE. 


The  in"sane,  especially  the  melancholic,  often  refuse  food  absa- 
lutely,  or  can  be  induced  to  take  it  only  very  sparingly. 

Forced  Feeding. — When  food  is  absolutely  refused  by  the  pa- 
tient, the  question  of  forced  feeding  must  be  considered  in  order  to 
tide  him  over  the  emergency  and  support  life  until  confusional  in- 
sanity or  delirium  subsides. 

Concerning  this  problem  opposite  views  are  held.  Some  alien- 
ists regard  the  operation  of  compulsory  feeding  as  good  mental  dis- 
cipline, others  decry  it,  and  defer  it  as  long  as  possible.  It  must  be 
understood  that  the  refusal  of  food  may  be  either  a  complication  or 
a  symptom  of  the  special  form  of  insanity  in  which  it  occurs,  and  the 
patient  should  be  carefully  studied  to  determine  which  condition  is 
present.  As  a  complication,  it  may  be  caused  by  central  nerve 
lesions  that  hinder  deglutition,  such,  for  example,  as  those  found  in 
either  acute  or  chronic  paralytic  dementia.  Or  digestive  disturb- 
ances, dyspepsia,  or  gastric  catarrh  may  cause  a  loss  of  appetite 
which  in  the  patient's  disturbed  mental  state  is  exaggerated  into  a 
refusal  of  all  food.  Such  local  disorders  may  themselves  cause  hal- 
lucinations or  delusions,  giving  rise  to  "  sitiophobia,"  or  horror  of 
■taking  food.  Obviously  in  such  cases  cure  of  the  complication  may 
be  sometimes  effected  by  treating  the  local  condition.  Lavage  will 
sometimes  relieve  it  entirely. 

When  the  refusal  of  food  is  purely  a  symptom  of  the  disease,  as 
it  occurs  in  melancholia  or  delusional  insanity,  an  attempt  should 
always  be  made  to  learn  the  exact  nature  of  the  delusion,  and  to  try 
if  it  cannot  be  dispelled  or  offset,  as  in  the  case  of  some  paranoiacs. 
For  example,  the  delusion  may  apply  merely  to  food  cooked  in  par- 
ticular ways,  or  served  in  a  certain  manner  or  by  certain  individuals, 
and  the  patient  may  have  no  real  loss  of  appetite,  but  may  even  try 
to  obtain  food  by  stealth  and  be  pleased  at  his  success  in  that  direc- 
tion, and  his  food  should  be  placed  where  he  can  find  it  unobserved. 

Some  patients  will  refuse  all  fluid  foods  who  are  willing  to  take 
solids,  or  vice  versa,  or  they  may  refuse  food  offered  by  an  attendant 
and  yet  accept  it  from  a  fellow-patient. 

If  their  delusions  take  the  form  of  suspicion  of  poisoning,  they 
may  sometimes  be  overcome  by  showing  them  eggs  in  the  shell, 
unpeeled  potatoes  and  fruits,  which  obviously  can  not  have  been 
poisoned  beforehand,  and  which  are  then  cooked  in  their  presence. 
Some  patients  will  only  eat  if  left  alone  or  after  others  have  fin- 
ished, because  they  feel  unworthy  to  eat  with  them.  Others  who  per- 
sistently refuse  food  will  take  it  greedily  if  an  apparent  show  of 
force  is  made  in  placing  it  within  their  mouths. 

Patients  with  chronic  mania  may  refuse  food  from  inattention, 
although  able  to  eat  if  their  surroundings  are  quiet  and  their  atten- 
tion can  be  momentarily  obtained.     If  they  can  be  induced  to  take 


THE   NERVOUS   SYSTEM.  589 

but  a  few  mouthfuls  at  a  time  they  should  be  fed  F^peatedly  at  short 
intervals. 

Food  should  be  cooked  and  served  as  temptingly  as  possible,  and 
the  patient,  if  unable  to  keep  himself  in  order,  should  have  his  mouth 
cleansed  and  clothing  protected  from  soiling. 

The  appetite  is  seldom  a  safe  guide  in  insanity,  and  when  it  fails 
completely  forced  feeding  should  not  be  postponed  until  the  patient 
has  become  too  exhausted  to  rally.  Cases  of  depressive  insanity  are 
very  apt  to  require  it  sooner  or  later,  and  sometimes  it  is  practised 
continuously  for  a  year  or  more.  In  acute  mania,  however,  it  may 
be  only  necessary  to  employ  the  method  for  a  few  days,  after  which 
the  patient  will  eat  of  his  own  accord  if  given  the  opportunity. 

In  cases  of  melancholia,  after  one  or  two  feedings  with  the  stom- 
ach tube,  I  have  often,  by  a  little  firmness  and  patience,  satisfied  the 
patient  that  swallowing  a  glass  of  milk  for  himself  was  more  agreea- 
ble than  having  it  poured  in  through  a  tube.  When  voluntary,  star- 
vation is  the  fixed  intent,  if  the  patient  can  be  convinced  that  he  has 
got  to  take  food  in  some  manner,  he  will  often  yield  to  the  inevita- 
ble and  choose  the  lesser  of  what  he  regards  as  two  evils.  With  a 
stomach  tube  in  one  hand  and  a  glass  of  milk  in  the  other  the  argu- 
ment can  be  made  very  forcible. 

The  physician  himself  should  always  direct  the  passage  of  the 
tube  for  the  first  few  times.  Afterwards,  if  the  patient  is  not  refrac- 
tory, an  attendant  may  do  it.  Occasionally  the  aid  of  two  or  three 
assistants  is  necessary  to  overcome  resistance.  The  patient  should 
be  made  to  sit  down  or  lie  upon  his  back,  and  either  an  oesophageal 
or  nasal  tube  may  be  used,  according  to  the  directions  given  on  page 
514.  There  are  certain  advantages  in  the  use  of  each  tube.  The 
oesophageal  tube  does  not  so  readily  admit  of  regurgitation  alongside 
of  it  as  the  nasal  tube  does  (although  occasionally  patients  can  re- 
gurgitate through  the  tube  itself).  If  it  be  filled  before  it  is  inserted, 
and  if  a  little  fluid  be  squeezed  out  of  it  when  part  way  down  the 
oesophagus,  reflex  swallowing  occurs,  which  may  be  taken  advantage 
-of  to  further  propel  the  tube.  The  disadvantage  of  this  method  of 
feeding  is  that  the  patient  often  struggles  and  must  be  gagged.  A 
wooden  gag  shaped  like  a  bit,  with  a  central  perforation  through 
which  the  tube  is  passed,  prevents  it  from  being  compressed  by  biting. 
But  the  gag  is  disagreeable,  it  may  slip  and  break  a  tooth,  and  the 
head  and  arms  must  be  rigidly  held  by  two' assistants.  I  have  known 
a  refractory  patient  with  melancholia  to  bite  off  and  swallow  eleven 
inches  of  stiff  oesophageal  tube,  which  remained  in  the  stomach  for 
eleven  days  before  it  was  ejected  by  vomiting ! 

The  nasal  tube  possesses  the  advantage  that  it  can  be  more 
easily  introduced  with  much  less  struggling,  but  it  has  the  disad- 
vantage  that    greater  care    is   required  to  prevent  passing  it  into 


590 


DIET   IN   DISEASE. 


the  larynx,  for  the  insane  are  sometimes  strangely  insensitive.  The 
former  difficulty  can  be  obviated  by  getting  the  patient  to  speak, 
or  by  closing  the  tube  after  it  has  been  inserted  and  before  fluid 
is  introduced,  in  order  to  make  sure  that  breathing  is  not  ob- 
structed. This  form  of  tube  should  be  of  as  large  a  size  as  can  be 
conveniently  passed.     A  No.  8  catheter  will  do. 

For  forced  alimentation  it  is  necessary  to  give  food  in  fluid  form, 
and  a  quart  of  milk,  with  one  or  two  beaten  eggs,  either  raw  or 
slightly  cooked  or  made  into  eggnog,  maybe  prescribed  two  or  three 
times  a  day.  Nutritious  meat  broths,  thickened  with  barley,  rice, 
or  vermicelli  and  strained,  or  potato  pur/e,  may  also  be  given  through 
a  large  tube.  In  a  case  lately  reported  by  H.  C.  Wood,  for  six  weeks 
the  patient  lived  with  the  greatest  benefit  on  six  pints  of  milk  and 
sixteen  raw  eggs  taken  daily.  If  an  ounce  of  malt  extract  be  added 
to  oatmeal  or  potato  gruel  in  milk,  it  soon  makes  the  mass  sufficiently 
fluid  to  pass  through  the  tube.  As  this  method  of  feeding  prevents 
the  saliva  from  commingling  with  the  food,  there  is  additional  ad- 
vantage in  giving  malt  or  diastase  to  replace  it. 

For  obstinate  patients,  feeding  with  the  tube  twice  a  day — at  say 
8  A.  M.  and  5  or  6  p.  m. — is  sufficient,  and  a  quart  of  food  can  be  intro- 
duced at  once,  but  more  feeble  patients  may  require  feeding  three  or 
four  times  a  day. 

If  gastric  catarrh  or  dyspepsia  is  present,  preliminary  lavage  may 
be  employed,  and  then  food  and  medicines  may  be  poured  through 
the  tube. 

Both  hypnotism  and  primary  anaesthesia  under  chloroform  have 
been  utilised  in  extreme  cases  to  enable  food  to  be  given  to  the  in- 
sane, but  the  latter  method  certainly  is  only  necessary  or  justifiable 
in  very  exceptional  cases. 

Nutrient  enemata  are  of  little  value  in  the  feeding  of  the  insane 
who  resist  feeding,  for  if  the  patient  realises  their  use  he  can  make  it 
more  difficult  to  be  nourished  in  this  way  than  by  the  stomach  or 
nasal  tube. 

Suralimentation. — Suralimentation  is  to  be  recommended  when 
feasible.     (See  page  438.) 

Brush  says :  "  In  acute  delirious  mania,  in  melancholia  with  frenzy, 
and  in  some  of  the  maniacal  seizures  incident  to  the  aged,  the  great 
importance  of  a  liberal  persistent  use  of  milk,  eggs,  and  animal  broths 
cannot  be  overestimated." 

If  patients  will  eat  they  should  be  given  abundant  nutritious  food, 
such  as  tender  meats,  custards,  cereals  with  cream,  eggnog,  thick- 
ened broths, />urees,  beef  jelly,  gruels,  etc.,  which  are  made  palatable 
to  tempt  the  appetite,  and  the  number  of  daily  meals  may  be  in- 
creased or  nourishment  may  be  given  once  in  three  hours.  By  di- 
verting the  blood  current  and  nervous  energy  for  digestive  processes, 


SKIN   DISEASES. 


591 


the  general  nervous  system  and  mental  condition  become  soothed  and 
quieted.     Fresh  fruit  should  be  offered  occasionally. 

Special  Precautions. — In  acute  insanity  there  is  a  tendency  for  the 
body  temperature  to  fall  two  or  three  or  more  degrees  below  the 
normal.  This  is  especially  true  of  those  cases  of  primary  dementia 
which  are  due  to  exposure  and  privation  accompanied  by  severe 
mental  strain,  such,  for  example,  as  occur  from  shipwreck  or  from 
any  form  of  severe  sudden  shock.  While  regulating  the  diet,  there- 
fore, attention  must  be  given  to  the  preservation  of  the  body  heat, 
and  the  patient  should  be  surrounded  by  uniform  temperature,  to 
be  maintained  in  an  overheated  room  or  by  hot-water  bottles  and 
warm  clothing.  Sustaining  the  normal  temperature  will  facilitate 
the  digestive  functions. 

The  insane  must  be  closely  supervised  while  eating.  They  often 
bolt  their  food,  when  given  too  much  at  a  time,  in  a  manner  that 
soon  destroys  digestion.  In  such  cases  all  food  should  be  given  in 
a  state  of  fine  subdivision  or  fluid  or  semifluid  form.  Patients  with 
advanced  general  paresis  or  different  paralytic  diseases  may  easily 
suffocate  by  getting  a  piece  of  meat  in  the  larynx.  Patients  with 
mania  gravis,  or  suicidal  melancholia,  etc.,  should  of  course  never  be 
intrusted  with  knives  or  with  plates  or  dishes  which  can  be  easily 
broken  into  sharp  fragments  with  which  to  cut  themselves. 

DIET  IN  SKIN   DISEASES. 

It  has  long  been  known  that  a  relation  exists  between  various 
errors  in  diet  and  certain  skin  diseases,  but  it  is  only  within  the  pastten 
or  fifteen  years  that  attention  has  been  directed  to  the  importance  of 
systematic  dietetic  treatment  to  aid  the  cure  of  such  ailments,  and  a 
more  thorough  investigation  of  this  subject  is  much  to  be  desired. 

Skin  Diseases  which  are  caused  by  Improper  Diet.— The 
skin  diseases  commonly  referable  among  other  influences  to  dietetic 
causes  are  erythema,  urticaria,  acne,  eczema,  and  scorbutic  erup- 
tions. 

Many  chronic  skin  diseases,  if  not  originally  caused  by  dietetic 
errors,  are  undoubtedly  much  protracted  and  made  worse  by  them. 
This  is  particularly  true  of  eczema  and  the  cutaneous  lesions  of 
scrofula,  and  sometimes  of  psoriasis. 

The  very  important  alimentary  substance  alcohol,  when  taken  in 
excess,  greatly  aggravates  many  forms  of  chronic  cutaneous  lesions, 
notably  those  of  syphilis  and  rosacea,  and  the  capillary  congestion 
and  muddy  complexion  of  chronic  alcoholism  is  well  known. 

The  modes  of  production  of  cutaneous  eruptions  by  dietetic 
errors  are  various.  Probably  in  the  majority  of  instances  such 
eruptions  are  due  to  malfermentation  products  which  are  absorbed 
40 


C-Q2-  r)l£T   IN   DISEASE. 

through  the  digestive  tract.  In  other  cases  they  may  be  due  to  an 
effort  to  eUminate  incompletely  oxidised  food  products  or  poisons 
from  the  cutaneous  glands  (as  in  the  case  of  drug  rashes),  and  it  has 
been  suggested  that  they  may  be  sometimes  caused  by  reflex  nerve 
irritation  from  the  alimentary  canal,  although  the  latter  theory  is 
less  tenable.  It  is,  however,  interesting  to  observe  the  fact  that  an 
intimate  relation  often  exists  between  irritation  and  inflammation  of 
the  skin  and  of  mucous  membranes. 

General  Principles  of  Dietetic  Treatment. — There  are  cer- 
tain general  principles  of  dietetic  treatment  which  are  applicable  to 
a  majority  of  all  severe  cases.  The  food  should  be  of  simple  kind, 
restricted  in  variety,  and  plainly  cooked.  Milk,  meat,  and  stale 
bread  are  more  desirable  than  amylaceous  or  saccharine  food.  If 
fever  is  present  at  the  outset,  a  milk  diet  must  be  ordered.  The 
strumous  and  gouty  require  fats  in  some  form.  Chronic  cases  with 
malnutrition  and  anaemia  must  have  abundant  nourishing  animal 
food.  In  the  case  of  scorbutic  eruptions  the  trouble  arises  some- 
times (but  not  always)  from  malnutrition  from  withholding  certain 
articles,  such  as  fresh  fruit  and  vegetables,  from  the  diet. 

Substances  to  be  particularly  avoided  in  skin  diseases  are  raw 
and  unripe  fruits  and  vegetables,  sweets  and  pastry  of  all  kinds,  con- 
diments and  highly  seasoned  dishes,  veal,  pork,  and  alcoholic  bever- 
ages. Other  injurious  foods  will  be  mentioned  under  the  treatment 
of  the  several  varieties  of  skin  diseases  described  below. 

Erythema. — Urticaria. 

Either  acute  erythema  or  urticaria  may  be  caused  in  some  per- 
sons by  eating  fish,  and  particularly  shellfish  and  crustaceans,  as 
oysters,  clams,  lobsters,  shrimps,  and  crabs.  It  is  also  produced  by 
strawberries,  bananas,  and  other  forms  of  fruit.  Crustaceans  and 
strawberries  are  perhaps  the  most  common  excitants. 

The  action  of  the  food  poison  is  wholly  different  from  that  of 
ptomaines  (page  350),  for  it  originates  from  fresh  as  well  as  stale 
food,  and  may  be  derived,  as  in  the  case  of  strawberries,  from  vege- 
table food.  Some  persons  have  an  attack  regularly  every  spring 
when  strawberries  first  appear  on  the  table.  Others  show  occasional 
immunity,  depending  upon  their  condition  at  the  time.  Those  per- 
sons who  are  hurt  by  one  kind  of  poisonous  food  are  not  necessarily 
affected  by  the  others.  The  whole  matter  seems  to  be  influenced 
solely  by  idiosyncrasy. 

Other  alimentary  substances  which  have  been  observed  to  some- 
times poison  are  pork  in  various  forms,  sausages,  mushrooms,  cheese, 
and  even  mutton  (Jackson). 

Symptoms. — The  eruption  develops  suddenly  and  within  from 
two  to  six  hours  after  ingestion  of  the  food.     It  is  commonly  a  typ- 


SKIN   DISEASES. 


593 


ical  urticaria  with  large  pink  wheals,  which  quickly  come  and  go  over 
all  parts  of  the  body.  They  are  accompanied  by  intense  itching  and 
burning.  This  affection  usually  lasts  but  a  few  hours,  or  possibly  for 
two  or  three  days,  though  sometimes  it  may  continue  for  several  weeks. 

Treatment. — The  eruption  usually  disappears  upon  withdraw- 
ing the  offending  article  from  the  diet,  and  giving  a  saline  cathartic 
and  some  simple  remedy  to  regulate  digestion  and  prevent  fermenta- 
tion, such  as  salol,  salicin,  or  rhubarb  and  soda. 

The  troublesome  itching  is  best  relieved  by  sponging  with  com- 
mon baking  soda,  a  teaspoonful  to  a  quart  of  water,  or  a  solution 
may  be  applied  to  the  wheals  of  menthol  and  chloral,  each  a  drachm, 
in  a  couple  of  ounces  of  a  mixture  of  equal  parts  of  alcohol  and 
camphor  water. 

Acne. 

Causation. — The  larger  number  of  cases  of  acne  are  produced 
by  improper  food.  The  papules  and  pustules  which  constitute  acne 
are  caused  by  inspissation  of  the  oil  of  the  sebaceous  glands,  which 
plugs  their  orifices  and  irritates  the  glands  and  the  hair  follicles,  ex- 
citing inflammation  in  them.  The  disease  is  usually  first  observed 
during  puberty,  a  period  in  which  important  changes  in  the  nutrition 
of  the  body  are  in  progress,  and,  once  established,  it  is  apt  to  last  for 
some  time — often  for  several  years.  It  is  easy  to  conceive  how 
slightly  altered  composition  of  the  blood,  due  to  imperfect  assimila- 
tion of  food,  may  alter  the  composition  of  the  sebum  and  irritate  the 
sebaceous  glands. 

In  some  people  the  papules  appear  as  a  result  of  eating  buck, 
wheat  cakes  or  oatmeal.  In  others  they  are  caused  by  greasy  food — 
doughnuts,  sausages,  cheese,  fried  meats,  ill-cooked  and  rich  pastry — 
excess  of  sweets,  nuts,  and  other  indigestible  substances. 

Dietetic  Treatment. — In  addition  to  local  means,  the  dietetic 
treatment  of  acne  is  most  important.  Jackson  says :  "  The  well-to-do 
are  all  prone  to  eat  too  much,  and  it  is  remarkable  how  rapidly  acne 
will  improve  by  reducing  their  diet  to  the  simplest  elements.  In 
many  of  them  a  milk  diet  for  a  few  days,  provided  milk  agrees  with 
them,  will  accomplish  a  marked  benefit.  It  is  a  good  rule  to  cut  off 
from  the  dietary  all  pastry,  cake,  candy,  sweets,  hot  breads  and  pan- 
cakes, greasy  soups,  articles  fried  in  fat,  twice-cooked  meats,  rich 
gravies — in  fact,  all  those  things  that  are  most  apt  to  tempt  the 
palate."  Alcohol  in  all  forms  should  be  prohibited,  as  well  as  tea 
and  coffee.  A  tumblerful  of  hot  water  or  a  glass  of  Vichy  should  be 
drunk  before  each  meal.  With  meals  but  little  fluid  should  be  taken, 
never  over  four  or  five  ounces,  but  between  meals  water  or  aerated 
water  should  be  drunk  freely  for  its  diuretiq  effect.  Naturally,  exer- 
cise, bathing,  and  the  use  of  laxatives  should  be  adjuncts  to  the  die- 
tetic regimen. 


^q^  diet  in  disease. 

Eczema. 

Causation. — Eczema,  both  acute  and  chronic,  which  constitutes 
so  large  a  proportion  of  all  cases  of  skin  diseases,  is  provoked  by 
different  causes,  but  in  a  great  number  of  instances  its  origin  is 
directly  traceable  to  dietetic  faults.  These  may  be  of  three  kinds — 
namely,  the  eating  of  (i)  too  much  food;  (2)  insufficient  food;  (3) 
improper  food. 

I.  Cases  due  to  Overeating. — The  ills  of  overeating  have 
been  elsewhere  described  (page  342).  Its  relation  to  eczema  con- 
sists in  the  additional  burden  thrown  upon  the  skin  of  attempting 
to  eliminate  waste  products,  which  are  accumulated  in  the  blood 
faster  than  they  can  be  got  rid  of.  The  cutaneous  glands,  like  the 
kidneys,  are  constantly  stimulated  and  overworked,  and  the  char- 
acter of  their  secretion  is  altered.  The  skin,  for  a  long  time  irri- 
tated, finally  succumbs  to  a  definite  eruption. 

It  is  for  this  reason  that  robust  persons  apparently  in  the  best 
of  health  and  with  too  vigorous  appetites  will  sometimes  be  sur- 
prised with  the  sudden  appearance  of  eczema,  which  they  have  al- 
ways attributed  solely  to  "bad  blood." 

Treatment. — This  class  of  cases  is  to  be  treated  by  reducing 
the  quantity  of  food,  and  by  prescribing  a  very  simple  diet.  In 
bad  cases  of  general  eczema  it  may  be  best  to  put  the  patient  upon 
a  milk  or  bread-and-milk  diet  for  one,  two,  or  three  weeks.  From 
two  to  two  and  a  half  quarts  are  taken  daily  with  toast  or  crackers. 
Marked  improvement  will  occasionally  follow  this  course.  For 
others,  simply  reducing  the  diet  by  excluding  meat  and  desserts  for 
a  time,  may  be  all  that  is  necessary.  Meats — either  beef,  mutton,  or 
chicken — should  not  be  allowed  more  than  once  a  day.  Piffard  re- 
ports that  56  per  cent  of  his  cases  were  accustomed  to  eat  meat  in 
excess  three  times  a  day. 

Fish,  either  boiled  or  broiled,  may  be  substituted  for  meat  to 
advantage  in  neurotic  subjects  (Bulkley),  for  though  it  may  excite 
urticaria,  it  does  no  harm  in  eczema  in  spite  of  the  popular  belief 
to  the  contrary.  I  have  known  the  eating  of  shellfish,  however,  to 
intensify  chronic  cases  considerably. 

Typical  Diet  for  Eczema. — The  following  simple  diet  may 
serve  as  an  example  : 

Breakfast. — Bread  and  milk,  or  porridge,  or  wheaten  grits,  or 
cracked  wheat,  without  cream  may  be  added,  and  salt  or  lemon  juice 
if  preferred.     Every  other  day  a  soft-cooked  e.'gg  may  be  eaten. 

Dinner. — No  soup,  entre'es,  or  dessert.  Roast  beef  or  mutton  or 
chicken  may  alternate  with  broiled  fresh  fish  with  white  meat,  one 
or  two  green,  light  vegetables,  such  as  haricots,  spinach,  lettuce, 
green  peas,  or  macaroni.     As  Jackson  says :  '•  It  is  a  good  rule  to 


SKIN   DISEASES. 


595 


tell  the  patient  he  may  eat  what  he  likes,  but  not  of  more  than  two 
dishes  at  a  meal.  It  is  unlikely  that  he  will  then  overeat."  Fresh, 
ripe  fruits,  except  apples,  may  be  allowed 

Supper. — Bread  or  toast  or  crackers  and  milk,  custard,  or  simple 
rice  pudding,  not  too  sweet.  A  little  fresh  fruit.  Stimulants  are 
not  usually  required,  but  if  needed  for  nutritive  or  tonic  effect,  di- 
lute liquor,  brandy,  whisky,  or  Hollands  is  the  best  form. 

Malt  liquors  of  all  sorts,  as  well  as  wines,  should  be  forbidden. 
It  is  quite  generally  believed  that  tea  and  coffee  are  harmful  in 
eczema,  and  drunk  in  excess  they  certainly  are  so,  not  only  from 
disordering  and  retarding  digestion,  but  from  their  undue  stimulat- 
ing effect.  Unless  they  are  taken  in  great  moderation  and  but  once 
a  day,  it  is  better  to  forbid  their  use  entirely.  The  same  is  true  of 
sweet  chocolate,  but  cocoa  may  be  allowed. 

2.  Cases  due  to  Insufficient  Food.— Too  little  food  results 
in  impoverished  nutrition,  and  the  skin,  being  one  of  the  most  sen- 
sitive organs  of  the  body,  is  among  the  first  to  suffer.  The  habits 
of  filth  which  so  often  accompany  semistarvation  among  the  poor 
are  contributing  causes  which  combine  to  provoke  skin  eruptions. 

The  diet  required  for  these  cases  does  not  essentially  differ  from 
those  of  the  preceding  class.  An  effort  should  be  made  to  restore 
the  impoverished  nutrition  of  the  body  as  quickly  as  possible  by 
suralimentation  if  necessary  (page  438). 

3.  Cases  due  to  Improper  Food. — Improper  food  is  also  capa- 
ble of  exciting  outbreaks  of  eczema,  and  this  is  particularly  true  of 
chronic  or  relapsing  cases.  Oatmeal,  for  example,  while  it  may  not 
cause  the  disease,  is  generally  believed  to  be  capable  of  intensifying 
it.  It  is  not  possible  to  always  forewarn  against  the  particular  arti- 
cles of  diet  which  will  do  this,  as  they  vary  in  different  individuals 
and  often  in  the  same  person  at  different  times,  but,  in  general,  food 
which  is  called  "  rich  "  is  to  be  avoided,  such  as  highly  seasoned 
meats,  soups,  sauces,  gravies,  strong  condiments,  sweets,  pastry,  hot 
breads,  pickles,  preserves,  and  fancy  desserts  of  all  kinds.  Bulkley 
especially  forbids  sweet  potatoes,  fried  eggplant,  cabbage,  cheese, 
bananas,  apples,  soda  water  with  sirups,  as  well  as  salt  food,  such 
as  ham,  corned  beef,  and  salt  pork.  A  little  bacon  or  a  salt  herring, 
however,  is  permissible.  All  fried  food,  with  the  above  exceptions, 
is  strictly  forbidden,  and  "  fritters,"  fried  oysters,  etc.,  are  highly  in- 
jurious. In  a  word,  all  those  articles  which  are  most  apt  to  excite 
temporary  dyspepsia  and  overload  the  urine  with  phosphates,  urates, 
and  calcium  oxalate  must  be  avoided.  The  staple  diet  should  con- 
sist of  whole-meal  bread,  fresh,  plainly  cooked  vegetables,  eggs, 
milk,  and  a  little  chicken,  fresh  fish,  or  meat  not  oftener  than  once 
a  day. 

There  are  obstinate  cases  of  chronic  eczema  which  fail  to  yield 


596 


DIET   IN   DISEASE. 


to  any  dietetic  regulations,  but  it  is  always  desirable  to  thoroughly 
try  the  value  of  dietetics,  and  very  often  the  result  will  be  surpris- 
ingly gratifying.  In  conjunction  with  dietetic  treatment  the  urine 
should  be  always  carefully  examined,  and  the  bowels  must  of  course 
be  regulated. 

It  is  very  important  to  control  the  general  habits  of  the  patient 
in  regard  to  meals.  He  should  eat  at  regular  and  proper  hours  and 
observe  uniformity  in  the  quantity  of  food  consumed.  He  should 
be  very  careful  to  eat  slowly  and  thoroughly  masticate  his  food,  and 
not  drink  so  much  fluid  with  meals  as  to  dilute  the  gastric  juice 
excessively.  The  general  rules  for  the  treatment  of  dyspepsia  (page 
500)  and  its  avoidance  are  especially  applicable  to  all  skin  diseases 
which  are  in  any  way  amenable  to  dietetic  influence.  It  should  also 
be  remembered  that  eczema  frequently  is  associated  with  gouty  and 
strumous  diatheses,  and  the  reader  is  referred  to  the  sections  upon 
these  subjects. 

ECZEMA   IN   NURSING   INFANTS. 

Bulkley  points  out  that  eczema  in  nursing  infants  is  mainly  due 
to  dietetic  errors  of  the  mother,  for  whom,  rather  than  for  the  child, 
treatment  should  be  instituted.  He  prohibits  the  drinking  of  all 
forms  of  malt  liquors  and  wines  and  rich  chocolate.  Anything 
which  provokes  indigestion  and  biliousness  in  the  mother  reacts  un- 
favourably upon  the  skin  disease  of  the  infant.  This  is  a  very  im- 
portant truth  too  often  overlooked.  If  the  mother  becomes  con- 
stipated, has  dyspepsia  and  a  furred  tongue,  and  excessive  deposit 
of  urates  and  oxalates  in  the  urine,  her  diet  must  be  changed,  the 
bowels  must  be  regulated,  and  tonics  should  be  given.  Other  cases 
in  infants  are  caused  by  the  mother's  milk  being  poor  and  thin,  and 
the  breast  milk  should  be  supplemented  by  cow's  milk  properly  pre- 
pared, or  it  may  become  necessary  to  wean  the  baby  completely. 
Mothers  often  nurse  their  infants  too  long,  hoping  thereby  to  post- 
pone conception.  When  the  breast  milk  is  too  poor  in  quality  Bulk- 
ley  believes  in  adding  fat  to  the  baby's  nourishment  in  the  form  of 
a  few  drops  of  cod-liver  oil  or  a  little  cream,  and  he  recommends 
inunctions  of  almond,  sweet,  linseed,  or  cod-liver  oil.  Cod-liver  oil  is 
cited  by  some  authorities  as  causing  eczema,  but  this  refers  to  its 
use  in  excess  when  the  digestion  is  deranged  and  dyspepsia  is 
aggravated  by  it.  Strumous  eczema  is  often  cured  by  adding  fat  to 
the  food. 

The  common  mistake  of  nursing  infants  too  often  is  particularly 
apt  to  occur  with  eczematous  babies,  whose  mothers  mistake  the 
child's  crying  for  a  manifestation  of  hunger,  whereas  it  is  often  excited 
by  the  extreme  itching  of  the  eruption,  which  the  infant  is  too  young 
or  too  feeble  to  scratch.     If  fed  oftener  than  once  in  two  hours  or 


SKIN   DISEASES. 


597 


more,  the  infant's  digestion  becomes  deranged,  and  any  existing 
eruption  is  made  more  unbearable.  Bottle-fed  infants  are  more 
likely  to  have  eczema  than  sucklings,  probably  because  they  oftener 
have  gastro-intestinal  disorders.  Underfed  infants  are  less  subject 
to  the  disease  than  are  the  overfed. 

ECZEMA  IN  CHILDREN. 
Eczema  in  young  children  is  often  due  to  dietetic  errors,  and  in 
all  cases  care  should  be  exercised  to  cure  it  by  regulation  of  the 
food.  The  commonest  fault  in  feeding  young  children  consists  in 
giving  them  too  much  starchy  food,  which  they  cannot  as  yet  digest, 
and  the  innumerable  prepared  infant  foods,  consisting  largely  of 
starches  and  sugars,  are  responsible  for  much  of  this  trouble.  Some 
parents,  aware  of  this  fact,  go  to  the  other  extreme,  and  give  the 
child  too  much  animal  food  in  the  form  of  meat  juice,  broths,  and 
eggs.  A  diet  improperly  balanced  in  either  direction  induces  a 
strumous  diathesis  with  a  special  tendency  to  the'development  of 
eczema.  Older  children  should  be  denied  candy,  chocolate,  and 
indulgence  in  sweets  of  all  sorts,  and  must  be  fed  upon  the  simplest 
diet,  in  which  starch,  and  especially  sugar,  should  be  reduced,  and 
pure  fat  increased.  The  latter  is  to  be  prescribed  in  the  form  of 
cream,  fresh  uncooked  butter,  fat  beef,  and  cod-liver  oil.  Bulkley 
recommends  the  use  of  whole-meal  bread,  cracked  wheat,  hominy, 
and  corn  grits  with  salt  and  butter  or  cream.  Oatmeal  is  prohibited  ; 
likewise  tea  and  coffee. 

EXFOLIATIVE   DERMATITIS. 

Exfoliative  dermatitis  should  be  treated  upon  substantially  the 
same  dietetic  plan  as  eczema.  An  exclusive  milk  diet  for  a  month 
or  six  weeks  may  prove  beneficial.  Jackson  advises  chewing  flax- 
seed or  taking,  in  milk,  several  ounces  of  flaxseed  tea  every  day. 

Rosacea. 

Causation. — Rosacea  is  a  chronic  skin  affection  disfiguring  the 
middle  parts  of  the  face,  about  the  nose,  mouth,  cheeks,  and  some- 
times the  forehead,  by  red  patches  of  dilated  capillaries. 

It  is  regarded  as  a  reflex  neurosis  of  the  local  vasomotor  nerves. 
It  is  oftenest  caused  by  erroneous  diet,  and  especially  by  strong 
drink,  which  dilates  the  facial  arterioles  and  also  excites  gastric 
catarrh.  Jackson  says  :  "  The  inordinate  use  of  strong  tea  acts  in 
the  same  way,  and  probably  gives  rise  to  as  many  cases  as  does 
alcohol." 

Dietetic  Treatment. — The  dietetic  treatment  is  very  impor- 
tant. It  involves  the  prohibition  of  all  alcoholic  drinks,  as  well  as 
hot  beverages  of  every  kind,  such  as  tea,  coffee,  and  soup.     Existing 


598 


DIET    IN   DISEASE. 


dyspepsia  should  be' treated,  and  all  rich  food,  desserts,  sauces,  pickles, 
strong  condiments,  dried,  salted,  or  canned  foods,  fried  substances, 
and  sweets  should  be  withheld.  The  patient  must  be  kept  for  sev- 
eral weeks  or  months  upon  a  low,  non-stimulating  diet  of  plainly 
cooked  food,  such  as  that  advised  for  the  treatment  of  eczema. 

Psoriasis. 

Causation. — Psoriasis  is  a  chronic  skin  disease  characterised  by 
the  appearance  of  isolated  red  patches  of  considerable  size,  covered 
by  shining  white  scales.  The  aetiology  of  this  eruption  is  not  under- 
stood. It  may  be  hereditary  or  follow  nerve  shock,  but  in  many 
cases  it  is  directly  attributable  to  imperfect  assimilation  of  nourish- 
ment, and  accumulation  of  waste  products  in  the  system,  such  as 
occur  in  gout  and  rheumatism. 

The  excessive  consumption  of  oatmeal  has  been  observed  to  cause 
it  (Hardaway). 

Dietetic  Treatment. — This  disease  is  less  amenable  to  dietetic 
treatment  than  are  some  other  skin  affections  ;  nevertheless,  this  must 
not  be  neglected,  as  it  may  prove  a  valuable  aid  to  local  measures. 
The  diet  should  always  be  restricted  both  in  quantity  and  variety. 
Some  patients  improve  upon  a  purely  vegetable  regimen  (Fox).  This 
is  true  of  obese  and  plethoric  patients.  In  bad  cases  it  will  be  best 
to  put  them  upon  a  bread-and-milk  diet  for  a  week.  Vegetable  food 
may  then  be  added,  but  sweets  and  meats  should  be  withheld. 
Feeble,  anaemic  patients  usually  improve  rather  upon  an  animal  diet, 
consisting  largely  of  milk,  with  eggs,  beef,  and  mutton.  Bread  may 
be  allowed.  Elaborately  cooked  and  highly  seasoned  food  must  be 
forbidden,  as  well  as  all  forms  of  malt  liquors.  If  any  alcohol  is  re- 
quired it  should  be  prescribed  in  the  form  of  well-diluted  whisky 
and  taken  only  with  meals,  but  as  a  rule  patients  are  far  better 
without  it. 

Pruritus. 
Patients  suffering  from  pruritus  should  partake  only  of  non-stim- 
ulating food.  They  must  particularly  avoid  tea,  coffee,  alcoholic 
drinks  of  every  variety,  condiments,  fish,  pastry,  cheese,  sauces, 
pickles,  made  dishes,  and  fried  food.  Tobacco  should  be  tempora- 
rily withheld. 

FURUNCULOSIS,  OR  BOILS. 
Furunculosis  is  often  wrongly  attributed  to  dietetic  errors  or  high 
living,  but  it  is  now  known  to  be  of  germ  origin  due  to  the  action  of 
the  Staphylococcus  pyogenes  aureus  et  albus,  which  penetrates  the  skin, 
through  abrasions  or  otherwise,  so  that  the  supposed  influence  of  diet 
is  only  remote,  in  that  poor  hving  tends  to  lower  the  general  vitality 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


599 


and  make  the  body  more  susceptible  to  any  form  of  inoculation. 
Special  dietetic  treatment  becomes  necessary  only  in  debilitated 
cases,  such  as  complicate  anaemia,  diabetes,  or  convalescence  from 
protracted  infectious  diseases,  and  the  rules  for  it  will  be  found 
under  those  headings. 


DISEASES   ESPECIALLY   INFLUENCED   BY  DIET. 

Obesity  (Polysarcia). 

Causation. — Obesity  is  a  diseased  condition  of  the  body,  de- 
pending upon  alteration  in  the  proper  balance  of  nutrition,  with  an 
accumulation  of  suboxidised  fat  in  and  between  the  tissues. 

It  may  affect  either  sex,  but  is  much  more  common  among  women, 
in  whom  it  is  particularly  noticed  during  and  after  the  climacteric. 

It  may  develop  at  any  age  after  early  childhood.  When  appear- 
ing early  it  is  usually  the  immediate  result  of  heredity.  It  is,  how- 
ever, most  common  after  middle  age,  when  the  functional  activity  of 
the  body  IS  diminished  and  when  habits  of  systematic  exercise  are  re- 
placed by  a  sedentary  life  of  luxury  and  ease,  combined  with  over- 
eating. 

Aside  from  heredity,  an  important  cause  of  obesity  is  excessive 
eating,  which  is  a  fault  among  the  majority  of  persons  who  have 
passed  middle  life.  When  the  growth  of  the  body  has  been  com- 
pleted there  is  a  stage  of  equilibrium  in  weight  which  lasts  for 
several  years,  and  the  waste  matter  of  any  excessive  food  taken 
is  eliminated  through  the  emunctories,  which  are  kept  active  by 
exercise  and  work.  After  middle  age,  activity  is  considerably 
diminished,  while  the  habit  of  fully  satisfying  a  vigorous  appetite 
may  be  continued,  resulting  in  the  consumption  of  a  larger  amount 
of  food  than  is  required  for  maintaining  the  vital  functions.  It  is 
extremely  difficult  for  people  who  feel  in  robust  health  and  whose 
mental  is  proportionately  greater  than  their  physical  activity,  to 
realise  that  they  not  only  require  less  food  than  they  did  ten,  fifteen, 
or  twenty  years  earlier  in  life,  but  that  eating  as  they  do  they  may 
be  producing  positive  harm  by  overloading  the  excretory  organs.  It 
is  for  this  reason  that  many  persons  accumulate  weight  after  reach- 
ing a  certain  advanced  period  of  life. 

/'According  to  Sir  H.  Thompson's  view,  overeating  in  the  first  half 
or  so  of  life  may  be  relieved  by  occasional  bilious  attacks,  which 
enable  the  system  to  cast  off  accumulated  waste,  but  later  "the  un- 
employed material  may  be  relegated  in  the  form  of  fat  to  be  stored 
on  the  external  surface  of  the  body  or  be  packed  among  the  internal 
organs,  and  thus  he  or  she  may  become  corpulent  and  heavy." 

The  constant  use  of  alcoholic  stimulation  in  its  milder  forms,  such 


5oo  I>IET   IN   DISEASE. 

^^s  beer  and  ale,  favours  obesity,  and  in  many  individuals  seems  to 
be  a  direct  cause  of  it.)  There  are  other  cases  in  which  it  is  difficult 
to  attribute  the  accumulation  of  fat  to  any  faults  in  either  eating  or 
drinking.  CVery  stout  persons  are  occasionally  extremely  moderate 
eaters,  and  in  these  cases  the  difficulty  lies  apparently  in  poor  oxi- 
dation and  insufficient  exercised 

The  condition  of  obesity  is  somewhat  modified  by  climate  and 
race.  It  is  less  common  in  the  United  States  than  it  is  among 
elderly  women  in  England  and  Germany. 

Not  infrequently  obesity  occurs  in  connection  with  pronounced 
anaemia  and  hysteria.  It  prevents  such  patients  from  taking  an 
ordinary  amount  of  exercise.  This  is  owing  to  the  increased  weight 
and  difficulty  of  moving  about,  as  well  as  to  the  lassitude  and  posi- 
tive dislike  for  muscular  exertion  which  is  felt  by  them.  Obesity 
once  established  is  apt  to  increase  unless  properly  treated. 

So  long  as  the  fat  is  simply  stored  up  as  adipose  tissue,  and  be- 
tween and  not  within  the  cellular  elements  of  the  body,  it  is  compar- 
atively harmless,  excepting  as  it  indicates  a  disproportion  between 
functional  activity  and  the  amount  of  fuel  taken  in  to  develop  force, 
and  excepting  also  as  it  may  interfere  with  personal  convenience  in 
movement  and  cause  greater  muscular  fatigue  from  the  increased 
work  thrown  upon  the  muscles  in  supporting  so  heavy  a  body.  In 
other  cases  (and  this  may  be  the  outcome  of  any  advanced  case  of 
polysarcia)  the  fat  may  invade  the  cellular  elements  of  the  body, 
particularly  the  muscles,  and  fatty  degeneration  is  produced  in  the 
muscular  tissues,  which  very  seriously  weakens  and  impairs  their 
functional  activity.  The  special  danger  in  all  cases  of  this  class  is 
that  the  heart  muscle  may  become  affected  in  this  manner,  which 
renders  it  liable  to  cease  beating  whenever  the  slightest  additional 
strain  is  thrown  upon  the  circulation.  It  follows  that  it  is  most  de- 
sirable in  the  dietetic  treatment  of  obesity  to  determine  the  original 
cause  of  fat  accumulation,  and  to  ascertain  to  what  extent  it  is  ac- 
I  ojmpanied  by  fatty  degeneration. 
^  Bauer  says :  "  The  fat  stored  up  in  the  body  acts  in  like  manner 
I  with  the  fat  contained  in  the  food,  since  it  likewise  lessens  the  waste 
^  of  tissue  and  secondarily  the  oxidation.  Thus  we  understand  why 
abstinence  can  be  longer  borne  by  organisms  rich  in  fat  than  by 
those  poorly  furnished  with  it,  the  former  consuming  less  of  the 
albumin  of  their  organs.  fThe  stock  of  fat  stored  up  in  the  body  is 
moreover  the  cause  why  corpulent  individuals  frequently  continue  to 
gain  in  bulk  although  they  are  not  in  the  habit  of  indulging  in  food 
immoderately.  \ 

I  "  If  an  increase  of  albumin  be  desired  without  a  considerable 
addition  to  the  store  of  fat,  a  liberal  allowance  of  albumin  with 
relatively  small  quantities  of  carbohydrates  must  be  provided.  N  If, 


led.N 


DISEASES  ESPECIALLY   INFLUENCED  BY   DIET.  6oi 

/on  the  other  hand,  a  substantial  addition  to  the  fat  appear  desirable, 
the  food  must  contain  less  albumin  and  more  carbohydrates,  with  a 
fair  proportion  of  fats."  J 

Voit  claims  that  albumin  circulating  in  the  blood  is  more  readily 
oxidised  than  either  fats  or  carbohydrates,  and  that  the  fat  existing 
in  the  tissues  acts  like  free  circulating  fat,  not  primarily  by  saving 
proteids  from  oxidation,  but  by  causing  a  larger  proportion  of  them 
to  enter  into  the  organised  tissues,  thus  saving  tissue  waste.  The 
tissues  use  up  the  circulating  albumin,  and,  not  being  exhausted 
thereby,  go  on  and  oxidise  the  fat  besides,  and  in  this  manner  the 
store  of  fat  in  the  body  is  reduced  on  a  meat  diet. 

An  exclusive  lean-meat  diet  increases  the  circulating  albumin, 
and,  the  nitrogenous  waste  being  correspondingly  increased,  fat  does 
not  accumulate  in  the  body.  If  now  fat  be  added,  then  fat  is  de- 
posited in  the  body. 

/^The  carbohydrates,  like  fat,  can  protect  circulating  albumin  from 
destruction  and  aid  its  transformation  to  organic  albumin,  but  it  is 
not  proved  that  they  themselves  make  fat,  as  at  first  supposed,  for 
they  are  very  completely  destroyed  even  when  eaten  in  excess.^  They 
merely  protect  other  foods  from  oxidation  under  such  conditions. 

Meat  and  carbohydrates  alone  increase  the  fat  in  the  body  with- 
out the  aid  of  fatty  food,  for  fat,  which  originates  from  splitting  up 
albumin,  is  spared  further  metabolism.  J 

Hence  fatty  metabolism  in  the  body  may  be  quite  independent  of 
fat  ingestion. 

Dietetic  Treatment. — The  question  of  the  treatment  of  obesity, 
owing  to  the  frequency  with  which  the  physician  has  to  deal  with  it, 
is  a  matter  of  great  importance,  and  demands  special  consideration. 
For  a  long  time  it  was  believed  that  excessive  consumption  of  car- 
bohydrates was  the  cause  of  increased  fat  production  within  the 
body.  The  pig  is  fattened  on  corn,  and  cattle  upon  various  cereals. 
Undoubtedly,  many  persons  who  are  of  spare  habit  can  increase 
their  weight  by  eating  a  larger  proportion  of  starches  and  sugars.  It 
is  a  fact,  moreover,  that  starches  contain  oxygen  in  the  exact  pro- 
portion necessary  for  the  formation  of  water  and  carbon  dioxide, 
and  on  being  disintegrated  in  the  body,  they  naturally  produce 
these  two  forms  of  waste  matter  which  are  promptly  eliminated 
from  the  surface  of  the  lungs  and  kidneys  respectively.  The  pro- 
teid  material  of  the  food  requires  a  larger  percentage  of  oxygen 
for  the  metabolism  involved  in  its  complete  conversion  into  urea. 

It  is  an  undoubted  physiological  fact  that  the  fat  of  the  body 
may  be  made  from  a  variety  of  different  foods,  and  that  some  indi- 
viduals are  capable  of  producing  it  from  a  particular  class  of  food 
materials  moite  readily  than  from  others.  Thus  one  person  may 
become  fat  from  overindulgence  in  saccharine  food  and  another  from 


^2  DIET   IN   DISEASE. 

eating  purely  starchy  foods  and  taking  large  quantities  of  malt  and 
beer,  and  still  another  from  the  excessive  use  of  quantities  of  fat 
meat.  Accordingly  the  rules  which  are  formulated  for  the  treat- 
ment of  obesity  must  be  regarded  as  referring  to  the  majority  of 
cases  only,  whereas  there  are  many  exceptions  which  must  be  indi- 
vidually studied. 

Many  special  dietetic  systems  are  in  vogue  for  the  treatment  of 
obesity.  In  some  cases  if  the  total  quantity  of  food  is  diminished 
no  special  diet  is  necessary,  but  in  many  persons  obesity  is  not  due 
to  overeating,  but  to  other  causes.  Some  patients  improve  at  once 
when  they  give  up  all  alcoholic  beverages.  An  ounce  of  food  eaten 
daily  in  excess  of  that  which  is  eliminated,  and  which  is  capable  of 
being  stored  in  the  tissues  in  the  form  of  fat,  very  soon  produces  a 
considerable  increase  in  the  body  weight,  which  in  a  year's  time 
would  amount  to  many  pounds. 

Among  the  different  systems  which  have  been  advocated  for  the 
cure  of  obesity  the  best  known  are  those  of  Banting,  Ebstein,  and 
Oertel.  Schweninger's  cure  is  practically  Oertel's  modified  by  with- 
holding fluid  from  the  meals,  and  giving  all  fluid  at  least  two  hours 
after  ingestion  of  food.    Schleicher's  system  is  also  similar  to  Oertel's. 

The  principal  systems  which  have  been  especially  devised  for  the 
treatment  of  obesity  will  be  separately  discussed  in  detail.  Nearly 
all  of  these  systems  agree  in  two  principles :  First,  to  reduce  the 
total  quantity  of  food  ingested  as  much  as  possible  without  impair- 
ing the  strength  of  the  patient.  Secondly,  to  diminish  the  amount 
of  fluid  drunk  by  prescribing  what  is  called  a  dry  diet.  The  treat- 
ment, moreover,  is  usually  accompanied  by  systematic  exercise  or 
bathing,  and  it  is  highly  important  to  keep  the  bowels  active. 

Some  persons  attempt  to  cure  obesity  by  allowing  the  patient  to 
eat  any  food  he  chooses,  but  insisting  that  he  shall  eat  only  one 
kind  of  food  at  any  one  meal.  As  a  natural  result,  the  appetite 
soon  palls,  and  he  eats  less  than  he  otherwise  would.  This  is  an 
unscientific  method,  and  an  unwholesome  one  for  serious  cases. 

As  a  general  principle,  corpulent  persons  should  restrain  them- 
selves to  as  great  an  extent  as  possible  from  drinking  fluids,  espe- 
cially with  meals.  Exceptions  to  this  rule  occur  when  obesity  compli- 
cates certain  other  diseases,  such  as  gout  or  rheumatism,  where  the 
use  of  an  increased  quantity  of  fluid  may  temporarily  be  necessary 
in  order  to  act  vigorously  upon  the  kidneys. 

Hot-water  beverages  taken  half  an  hour  before  meals,  and  again 
at  night  and  on  rising  in  the  morning,  are  beneficial,  and  less  fluid  is 
required  with  the  meals. 

As  a  rule,  never  more  than  five  ounces  of  fluid  should  be  taken 
with  a  meal,  or  fifteen  ounces  per  diem,  and  this  amount  may  be 
still  further  curtailed  by  giving  water  between  meals  instead. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  603 

'  Soups  of  all  kinds  should  be  forbidden  as  well  as  alcoholic 
beverages,  and  what  little  fluid  is  allowed  should  consist  of  plain  or 
aerated  water.  But  little,  if  any,  milk  should  be  taken.  The  food 
should  be  as  dry  as  possible  without  interfering  with  its  flavour  and 
nutrient  value.  Highly  succulent  fruits,  such  as  watermelons,  and 
vegetables  like  raw  tomatoes,  which  consist  largely  of  water,  should 
not  be  eaten.  Sugar  should  be  absolutely  forbidden,  and  fat  must 
be  used  very  sparingly,  and  only  in  the  form  of  a  little  butter. 
The  allowance  of  farinaceous  food  must  also  be  cut  down  as  much 
as  possible.  It  will  not  usually  be  found  practicable  to  do  without 
bread  for  any  length  of  time,  but  patients  are  often  willing  to  re- 
strict themselves  to  a  very  rigid  diet  for  two  or  three  weeks  if  the 
positive  hope  of  cure  or  amelioration  of  symptoms  can  be  held  out 
to  them,  if  they  are  made  to  understand  the  rationale  of  the  treat- 
ment, and  if  they  are  given  some  objective  point  to  anticipate  when 
a  promised  improvement  will  admit  of  greater  laxity  in  regard  to 
diet.  If  desirable,  gluten  bread  may  be  substituted  for  wheaten 
bread. 

The  deprivation  of  starchy  foods  can  always  be  better  and 
longer  tolerated  if  a  little  fat  is  given,  and  the  obese  do  not  well  en- 
dure deprivation  of  all  fats,  even  when  starchy  food  is  supplied  in 
moderation. 

This  is  more  often  true  of  those  engaged  in  mental  work  than  of 
those  employed  in  muscular  exercise.  Salts  and  fresh  green  vege- 
tables— "  vegetables  which  grow  above  the  ground  " — should  not  be 
withheld. 

Lean  meat  should  form  the  basis  of  all  diet,  but  an  unrestricted 
flesh  diet  in  obesity  may  give  rise  to  dyspepsia  and  gastric  and 
intestinal  catarrh. 

THE   BANTING   SYSTEM. 

The  diet  which  Mr.  Banting  practised  upon  himself  and  others 
with  considerable  success,  and  which  bears  his  name,  was  exceedingly 
rigid  in  regard  to  restricting  the  quantity  of  food  and  in  forbidding 
starches  and  sugars  to  the  greatest  degree  possible.  The  patients 
were  starved  to  the  extent  of  being  allowed  only  between  twenty-one 
and  twenty-seven  ounces  of  dry  food  in  the  twenty-four  hours,  about 
one  half  of  which  was  meat.  Only  two  ounces  of  bread  could  be 
taken,  and  the  balance  of  the  diet  was  composed  of  fresh  fruits  and 
the  lighter  forms  of  green  vegetables.  The  fluid  drunk  in  each 
twenty-four  hours  was  reduced  to  thirty-five  ounces.  It  should  be 
remembered  that  the  normal  quantity  of  urine  passed  by  an  adult 
is,  on  the  average,  fifty-two  ounces  in  addition  to  the  water  lost  by 
perspiration  and  respiration.  His  dietary,  which  was  based  on  the 
suggestions  of  his  physician,  Dr,  W.  Harvey,  has    been  found  too 


6o4 


DIET   IN   DISEASE. 


severe  in  many  cases,  and  is  apt  to  enfeeble  the  digestion,  especially 
when  patients  are  too  quickly  restricted  in  their  food,  and  at  present 
it  is  not  much  prescribed  in  this  country,  excepting  in  modified 
forms.  The  fats  and  albuminoids  are  not  well  balanced  in  this 
diet,  and  it  is  apt  to  cause  constipation  and  malnutrition. 

•  Mr.  Banting  began  his  treatment  upon  himself  in  1862,  and  in  a 
single  year  lost  forty-six  pounds  in  weight.  Sudden  restriction  in  diet 
in  obesity  may  sometimes  precipitate  attacks  of  renal  or  hepatic  colic 
from  the  presence  of  calculi.  Their  deposition  is  brought  about  by 
altering  the  composition  of  the  blood,  and  while  practising  any 
dietetic  system  for  obesity  one  should  be  certain  that  the  elimina- 
tion of  waste  matter  from  the  system  is  not  impaired,  as  it  is  apt  to 
be  if  water  is  too  suddenly  withheld.  On  this  account  largely  the 
stricter  diets  for  corpulency,  such  as  the  Banting  system,  sometimes 
result  in  failure  by  producing  a  condition  of  the  system  which  is  far 
worse  than  the  original  corpulency, 

THE   EBSTEIN   SYSTEM. 

The  Ebstein  treatment,  as  originally  employed  in  Germany,  has 
been  attended  with  considerable  success.  The  theory  of  this  system 
is  that  animal  as  well  as  carbohydrate  food  is  capable  of  being  con- 
verted into  fat,  especially  when  used  in  combination  with  starches 
and  sugars.  The  latter  are  believed  to  furnish  force  for  the  body, 
and  by  their  combustion  to  spare  the  complete  oxidation  of  albu- 
minates, which  are  therefore  stored  in  the  tissues  in  a  suboxidised 
form.  It  is  a  part  of  this  theory  that  fatty  food  does  not  give  rise 
to  or  promote  the  storage  of  fat  in  the  body,  and  hence  it  may  be  al- 
lowed in  the  dietary  ;  in  fact,  Ebstein  recommends  its  use  on  account 
of  its  effect  in  producing  satiety.  By  sooner  diminishing  the  ap- 
petite, there  is  less  craving  for  other  food  and  drink.  In  accordance 
with  this  belief,  he  proscribes  the  use  of  sugar,  potatoes,  and  all 
forms  of  farinaceous  food  with  the  exception  of  three  ounces  and  a 
half  of  bread,  which  is  allowed  each  day.  He  permits  the  use  of  fats, 
such  as  fat  meat,  cream,  butter,  and  fatty  soups.  Among  vegetables 
he  allows  asparagus,  spinach,  cabbage,  peas,  and  beans.  A  moderate 
amount  of  meat  of  any  kind  is  also  included.  The  quantity  of  fluids 
allowed  is  restricted.  Ebstein  allows  the  patient  to  take  three  meals 
a  day. 

Breakfast  consists  of  a  cup  of  black  tea  without  sugar  or  milk 
and  two  ounces  of  buttered  toast. 

Dinner,  which  is  given  at  noon,  comprises  a  meat  soup  or  broth, 
four  to  six  ounces  of  boiled  or  roasted  fat  beef  with  meat  gravy,  not 
thickened,  one  or  two  fresh  vegetables,  in  moderation,  and  for  des- 
sert salads  and  fresh  or  dried  fruits.  He  allows  a  little  light  wine 
and  black  tea  without  milk  or  sugar. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


605 


Supper  includes  tea  as  before,  a  soft-cooked  egg  and  a  moderate 
allowance  of  fish,  ham,  or  cold  fat  meat,  an  ounce  of  thin  buttered 
bread  or  toast,  and  fresh  fruit. 

Comparison  of  Dietaries  for  Corpulence  with  Ordinary  Dietaries  (Atkinson). 


DIETARIES. 


Banting  system 

Ebstein  system 

Play  fair's   standard    for   "  subsistence 

diet" 

Playfair's    standard    for    adults   with 

moderate  exercise 

Voit's  standard  for  labouring  man  at 

moderate  work 

Atkinson's    standard    for    man    with 

light  exercise 

Atkinson's  standard  foT  labouring  man 

at  moderate  work 

Poor  sewing  girl,  London  ;  diet  barely 

sufficient  for  subsistence 

University  professor,  Germany  ;  very 

little  exercise 

Well-to-do  family,  Connecticut ;  food 

actually  eaten 

Mechanics    and     factory    op>eratives, 

Massachusetts;  food  purchased..,. 
Food  actuallyeaten  by  college  students: 

From  Northern  United  States 

From  Eastern  United  States 


NUTRIENTS. 

Potential 
energy  in 
nutrients. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total. 

Grammes. 
171 
102 

Grammes. 

8 
85 

Grammes. 

75 
47 

Grammes. 
254 
234 

Calories. 
1,085 
1,400 

57 

14 

341 

412 

1,760 

119 

51 

531 

701 

3,140 

118 

56 

500 

674 

3.050 

100 

100 

360 

560 

2,815 

125 

125 

450 

700 

3,520 

53 

33 

316 

402 

1,820 

100 

100 

240 

440 

2,325 

128 

177 

466 

771 

4,080 

127 

186 

531 

844 

4,430 

138 
104 

184 
136 

622 
421 

944 
661 

•4,825 
3,415 

THE   OERTEL   SYSTEM. 

A  more  recent  system  for  the  dietetic  treatment  of  obesity  is  that 
practised  by  Oertel  and  modified  by  Schweninger.  The  distinctive 
feature  of  the  Oertel  treatment  is  the  attention  which  is  paid  to  im- 
proving the  condition  of  the  circulation  by  strengthening  the  heart 
action,  and  this,  he  claims,  so  much  improves  the  general  condition  of 
the  patient  that  the  fat  once  eliminated  is  not  reformed.  According 
to  his  theory,  corpulent  patients  may  be  subdivided  into  two  different 
classes,  whose  diet  is  regulated  accordingly.     They  are: 

"  (a)  Cases  of  fat  accumulation  in  which  the  respiratory  and  cir- 
culatory apparatus  have  undergone  no  special  derangement,  and  the 
patient  is  capable  of  muscular  effort  and  locomotion.  A  much  more 
serious  form  is  that  in  which  the  condition  of  fatty  heart  is  present, 
with  consequent  enfeeblement  of  circulation  and  visceral  engorge 
ment. 

"(/J)  Cases  in  which,  in  consequence  of  advanced  stasis  and 
hydraemia  (with  deficiency  of  haemoglobin),  the  amount  of  oxygen 
taken   up  from  the  lungs  is  extremely  reduced,  and  the  slightest 


5o6  I>IET   IN   DISEASE. 

muscular  efforts  are  enough  to  disturb  the  respiration  and  provoke 
dyspnoea." 

For  the  first  class  his  maximum  allowance  of  fat  is  fifty  grammes 
and  of  carbohydrates  two  hundred  grammes,  with  a  minimum  of  one 
hundred  and  fifty  grammes  of  albumin.  For  the  second  class  the 
maximum  allowance  of  fat  is  twenty-five  to  thirty  grammes,  with  one 
hundred  grammes  of  carbohydrates,  but  the  albumin  must  consider- 
ably exceed  one  hundred  and  fifty  grammes.  In  this  class  especially 
the  amount  of  fluids  drunk  must  be  curtailed.  By  withholding  fluid, 
Oertel  argues,  blood  pressure  is  reduced,  venous  stasis  is  lessened, 
the  vessels  of  the  body  will  adapt  themselves  to  the  reduced  quan- 
tity of  fluid,  and  to  supply  the  glandular  organs  and  muscles  with 
their  normal  proportion  fluid  will  be  "  drained  away  from  places 
where  the  tissue  changes  are  less  energetic,  and  which  are  less 
favourably  innervated.  Such  vessels  are,  above  all,  in  the  fatty 
tissues — vessels  branching  in  the  panniculus  adiposus." 

Nutritive  changes  ensue  in  the  fatty  tissues,  the  fat  is  disin- 
tegrated, conveyed  away,  and  burned  up. 

This  is  certainly  an  ingenious,  and  withal  very  plausible  theory 
which  has  many  facts  of  clinical  observation  to  recommend  it. 

Besides  holding  the  view  that  the  fluid  in  the  body  must  be  re- 
duced before  the  accumulated  fat  can  be  diminished,  Oertel  says : 
"  Since  the  force  required  to  raise  the  body  through  a  great  height 
entails  the  destruction  of  large  quantities  of  fat,  the  above  exertion 
[mountain  climbing]  will  also  lessen  the  fat  accumulation,  on  condi- 
tion only  that  we  give  less  fat  and  carbohydrates  in  the  food  than  are 
used  up  in  the  work  done." 

He  gives  some  fat  and  carbohydrate  food,  but  not  very  much, 
with  proteids,  for  he  believes  that,  anaemia  being  present,  an  exclu- 
sive meat  diet  would  not  be  completely  oxidised.  It  is  better,  there- 
fore, to  restrict  all  three  classes  of  foods,  but  not  to  entirely  exclude 
either,  and  the  proteids  must  decidedly  preponderate. 

He  also  believes  that  anaemia  has  weakened  the  vascular  tone 
through  supplying  a  blood  deficient  in  circulating  albumin,  and 
hence  a  diet  rich  in  proteids  is  further  indicated. 

The  Oertel  system  includes  almost  twice  the  quantity  of  animal 
food  allowed  in  the  Ebstein  diet,  and  double  the  quantity  of  carbo- 
hydrates and  less  than  half  the  quantity  of  fats.  It  is  distinguished 
from  the  Banting  system  also  by  the  greater  preponderance  of  fats 
and  starches.  The  following  table  from  Yeo  contrasts  these  differ- 
ent systems  of  diet.  For  comparison,  the  diet  of  Voit  is  added, 
which  gives  the  proportion  of  the  three  chief  varieties  of  foods  upon 
which  a  man  in  health  will  decrease  in  weight.  The  figures  rep- 
resent grammes : 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


607 


Daily 

Diet. 

Albuminates. 

Fats. 

Carbohydrates. 

Moleschott,  normal  average 

130 
140 
170 
100 

155-179 

84 
44 
10 

85 
25-40 

404 

165 
80 

Voit,                  "              "       

Ebstein,            "              "       

50 
70-110 

Oertel,               "              "       

It  will  be  observed  that  in  all  these  diets  the  starches  and  sugars 
chiefly  are  proportionately  much  reduced,  and  the  more  liberal 
dietary  of  Oertel  is  particularly  suitable  for  those  classes  of  cases  in 
which  exercise  can  be  joined  with  dietetic  treatment.  The  combined 
effect  of  the  diet  with  exercise  results  in  the  absorption  and  oxida- 
tion of  the  fat  deposited  between  the  muscular  tissues  and  in  the 
renewal  of  more  vigorous  action  of  the  muscle  fibres,  which  are 
shielded  from  waste  by  the  liberal  proportion  of  proteid  food  which 
is  admitted.  The  whole  treatment  is  aimed  especially  at  increasing 
the  vigour  and  force  of  the  heart  action,  and  in  many  cases  it  suc- 
ceeds admirably.  In  the  more  serious  type  of  obesity  the  deposition 
of  fat  around  the  base  of  the  heart  as  well  as  between  and  within 
the  heart  muscle  fibres  enfeebles  the  strength  of  the  cardiac  systole 
and  results  in  engorgement  of  the  venous  circulation.  The  heart  is 
unable  to  propel  the  blood  through  the  arteries  and  capillaries,  and 
there  is  very  little  vis  a  tergo  remaining  for  the  blood  in  the  veins. 
Lack  of  exercise  also  retards  the  venous  circulation.  As  a  result, 
there  is  a  constant  venous  congestion  which  is  particularly  notice- 
able in  the  viscera,  and  there  may  be  dropsical  accumulations  in  the 
different  serous  cavities  or  general  anasarca. 

Exercise. — In  the  treatment  of  such  cases  Oertel  withholds 
fluid  from  the  diet  as  much  as  possible,  and  to  assist  the  elimination 
of  water  from  the  body  the  patient  is  made  to  exercise  by  climbing 
carefully  graded  paths,  which  are  measured  and  adapted  with  refer- 
ence to  use  by  patients  of  different  strength.  During  muscular  exer- 
tion the  destruction  of  non-nitrogenous  food  stuffs  is  increased. 

Palpitation  and  dyspnoea,  which  are  so  frequent  accompaniments 
of  excessive  obesity,  are  not  especially  dreaded,  and  exercise  is 
pushed  until  these  symptoms  occur — that  is,  the  patients  are  made  to 
climb  the  graduated  ascents,  walking  slowly  and  systematically  and 
covering  a  prescribed  distance  each  day.  As  soon  as  they  experi- 
ence palpitation,  or  if  shortness  of  breath  appears,  they  are  to  stop 
and  rest  standing  until  the  breath  is  regained.  In  this  way  it  is 
believed  by  Oertel  that  the  heart  action,  is  actually  strengthened, 
and  the  fat  is  certainly  reduced.  Of  course,  due  care  must  be  ob- 
served to  prevent  exhaustion,  and  the  patients  must  be  warned 
41 


6o8  I^IET   IN    DISEASE. 

against  any  sudden  movement  or  overexertion  which  might  occasion 
fatal  heart  strain.  This  exercise  by  cHmbing  ascents  is  sometimes 
called  the  "terrain  cure." 

In  case  the  patient  is  unable  to  take  any  exercise  at  all,  the  ob- 
ject is  attained  by  massage  and  friction,  and  the  promotion  of  per- 
spiration is  secured  by  baths  of  different  sorts.  In  the  treatment  of 
such  cases,  among  the  solid  ingredients  of  the  food,  the  fats  and 
starches  are  still  further  reduced. 

Anaemia  is  believed  to  be  counteracted  by  the  use  of  albuminous 
food,  and  the  following  articles  are  allowed  when  this  is  a  prominent 
symptom  :  Lean  roast  and  boiled  beef  and  veal,  mutton,  game,  and 
eggs.  Vegetables,  spinach,  and  cabbage  may  be  eaten.  From  four 
to  six  ounces  of  bread  per  diem  are  given,  and  fats  and  starches  are 
restricted  as  much  as  possible,  ancf  sugars  are  withheld  altogether. 
The  fluid  prescribed  consists  of  a  moderate  cup  (about  six  ounces) 
of  coffee  or  tea  or  milk  twice  a  day,  with  twelve  ounces  of  wine  with 
an  equal  quantity  of  water,  which  may  be  taken  at  dinner.  If  pa- 
tients perspire  very  freely,  a  somewhat  larger  quantity  may  be  given, 
and  no  other  beverages  of  any  kind  are  permitted. 

The  fluid  allowed  should  not  all  be  taken  with  the  meals,  but 
may  be  drunk  at  intervals  between  the  times  of  eating  to  allay  thirst. 
In  the  less  serious  type  of  cases,  where  the  heart  action  is  unim- 
paired, Oertel  allows  the  fluid  to  be  gradually  increased,  and  he 
gives  four  to  six  ounces  of  wine  at  noon  time,  with  a  half  bottle  in 
the  evening. 

Bathing  should  be  carried  out  systematically,  and  the  patient 
may  be  packed  with  cloths  dipped  in  hot  water  in  order  to  promote 
perspiration.  The  baths  are  given  at  least  twice  a  week  through  a 
period  of  a  month  or  more. 

A  typical  menu  under  the  Oertel  treatment  is  the  following  : 

Oertel' s  Diet  for  Obesity. 

Morning. — One  cup  of  coffee  or  tea,  with  a  little  milk — altogether 
about  six  ounces ;  bread,  about  three  ounces. 

Noon. — Three  to  four  ounces  of  soup,  seven  to  eight  ounces  of 
roast  or  boiled  beef,  veal,  game,  or  not  too  fat  poultry,  salad  or  a 
light  vegetable,  a  little  fish  (cooked  without  fat),  if  desired,  one 
ounce  of  bread  or  farinaceous  pudding  (never  more  than  three 
ounces),  three  to  six  ounces  of  fruit,  fresh  preferred,  for  dessert.  It 
is  desirable  at  this  meal  to  avoid  taking  fluids,  but  in  hot  weather  or 
in  the  absence  of  fruit,  six  to  eight  ounces  of  light  wine  may  be  taken. 

Afternoon. — The  same  amount  of  coffee  or  tea  as  in  the  morning, 
with  at  most  six  ounces  of  water,  and  an  ounce  of  bread  as  an  ex- 
ceptional indulgence. 

Evening. — One  or  two  soft-boiled  eggs,  an  ounce  of  bread,  per- 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  609 

haps  a  small  slice  of  cheese ;  salad  and  fruit,  six  to  eight  ounces  of 
wine  with  four  or  five  ounces  of  water. 

After  patients  have  undergone  a  special  course  of  treatment  for 
obesity  and  their  weight  has  been  sufficiently  reduced,  it  is  desirable 
to  establish  a  diet  for  them  which  will  prevent  a  return  of  the  fat. 
For  this  purpose  Oertel  recommends  the  following  regimen  after  a 
nine  years'  experience  with  this  class  of  cases  ;  it  is  intended  for 
patients  in  whom  obesity  has  complicated  organic  disease  of  the 
heart  or  lungs : 

'■''Morning. — One  cup  of  coffee  or  tea  with  some  milk  =  150 
grammes  (6  ounces),  and  bread  =  75  grammes  (2'/,  ounces). 

'■'■Midday. — Soup  =  100  grammes  (3%  ounces) ;  lean  meat,  roasted 
or  boiled,  game  or  fowl  =  200  .grammes  (7  ounces) ;  fish,  not  too 
fat  =  25  grammes  (nearly  i  ounce) ;  bread  or  starch  stuffs  =  100 
grammes  at  most  (37^  ounces) ;  as  dessert  100  to  200  grammes  (3'/^  to 
7  ounces)  of  fruit,  fresh  preferred — a  smaller  quantity  if  preserved, 
especially  by  Nagelis's  method.  Liquids  are  better  avoided.  At 
dinner  time,  only  in  very  hot  weather  or  in  the  absence  of  fruit, 
perhaps  '/g  to  '/,  litre  of  light  wine  may  be  allowed  (6  to  9  ounces). 

'■'■Afternoon. — The  same  quantity  of  coffee  or  tea  as  before,  with 
at  most  '/g  litre  of  water  (6  ounces) ;  occasionally  25  grammes  of 
bread  (nearly  i  ounce). 

^'Evening. — One  or  two  soft'-boiled  eggs;  meat,  150  grammes 
(nearly  5  ounces) ;  bread,  25  grammes  (nearly  i  ounce) ;  a  bit  of 
cheese,  a  little  salad  and  fruit.  As  a  regular  drink,  '/^  to  '/^  litre  of 
wine  (6  to  9  ounces),  with  perhaps  '/g  litre  of  water  (4'/,  ounces)." 

Water  should  never  be  allowed  in  quantity,  and  what  little  is 
drunk  should  be  distributed  through  the  day. 

THE   SCHWENINGER   SYSTEM. 

Schweninger's  system  is  essentially  that  of  Oertel,  but  the  for- 
mer absolutely  forbids  the  use  of  drink  of  any  kind  with  meals, 
and  the  little  fluid  that  is  permitted  must  be  taken  fully  two  hours 
afterwards. 

His  treatment  is  substantially  as  follows  :  Moderate  exercise  for 
an  hour  before  breakfast,  after  a  cold  bath  with  friction. 

Breakfast,  8  A.  M. — Meat,  eggs,  or  milk.     A' walk. 

Second  Breakfast,  10.30  a.  m. — Meat  or  fish  and  a  glass  of  white 
wine.     A  walk. 

Dinner,  i  p.  M. — Meat,  vegetables,  and  fruit  compote. 

Supper,  7  p.  M. — Meat  and  fruit  compote  or  salad,  a  glass  of 
white  wine. 

No  other  fluid  is  given  with  meals.  Bread  is  eaten  very  spar- 
ingly. 


5 10  DIET   IN   DISEASE. 

Schleicher's  Diet  for  Obesity. 

Breakfast,  7  A.  m. — A  mutton  or  veal  cutlet  or  a  portion  of  sole 
as  big  as  the  palm  of  the  hand  ;  the  same  quantity  oS  bread  without 
butter.  8  a.  m. — A  cup  of  tea  with  sugar.  10.30  a.  m. — A  sand- 
wich of  bread  and  meat  or  sausage. 

Noon. — Meat,  eggs,  green  vegetables,  cheese,  an  orange.  Two 
glasses  of  white  wine.  (No  soup,  no  potatoes.)  4  p.  m. — Tea,  with 
sugar.  7  P.  M. — A  small  quantity  of  bread  and  cheese.  9  p.  m. — 
Cold  meat,  eggs,  salad.     Two  glasses  of  wine,  and  sometimes  more. 

This  is  practically  the  diet  of  Schweninger,  but  without  the 
absolute  prohibition  of  drink  at  meals. 

THE   GERMAIN    SEE   SYSTEM. 

Germain  S^e,  who,  holds  some  original  theories  in  regard  to 
dietetics,  declares  that  the  use  of  abundant  drink  is  distinctly  in- 
dicated in  the  treatment  of  obesity.  He  allows  a  diet  of  proteids 
and  fats,  withholding  sugars  and  starches,  and  requires  his  patients 
to  drink  hot  weak  tea  and  water  in  large  amount.  He  prohibits 
alcohol  in  every  form,  excepting  a  little  dilute  wine,  which  may  be 
allowed  in  exceptional  cases.  His  treatment  is  no  doubt  more 
serviceable  in  those  cases  of  corpulency  which  complicate  gout  and 
rheumatism  and  in  which,  as  above  mentioned,  it  is  desirable  to 
eliminate  the  waste  matter  from  the  system'-as  completely  as  pos- 
sible. 

THE   WEIR    MITCHELL   SYSTEM. 

Weir  Mitchell,  for  the  treatment  of  obesity,  relies  mainly  on  rest 
and  passive  exercise  in  the  form  of  massage  and  Swedish  move- 
ments with  a  skimmed-milk  diet,  which  latter  may  be  given  at  in- 
creasing rate,  gradually  replacing  the  accustomed  food,  until  in  a 
week's  time  the  patient  is  living  wholly  upon  milk.  Upon  this  diet, 
the  patient  may  lose  half  a  pound  or  more  in  weight  per  diem. 
Careful  watch  is  kept  of  the  strength.  The  patient  should  be  fre- 
quently examined  with  special  reference  to  loss  of  weight  and  to 
any  unfavourable  increase  in  the  heart  action  or  feebleness  of  the 
pulse.  If  the  latter  conditions  arise,  it  may  be  necessary  to  increase 
the  diet  or  to  give  stimulation.  Weir  Mitchell  is  accustomed  to 
allow  a  small  quantity  of  beef,  chicken,  or  oyster  soup  in  such  cases 
to  relieve  the  monotony  of  an  exclusive  milk  diet.  The  patient  is 
kept  quiet  in  bed  for  ten  days  or  a  fortnight,  and  afterwards  allowed 
to  move  about  the  room,  but  must  spend  most  of  his  time  upon  a 
lounge.  Massage  is  performed  once  or  twice  a  day  at.  first,  and 
subsequently  the  more  active  Swedish  movements  are  applied  to 
the  extremities.  After  from  four  to  six  weeks  of  this  treatment 
the  weight  is  usually  reduced  by  a  number  of  pounds,  and  the  gen- 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  6ll 

eral  condition  and  strength  are  found  to  have  improved.  The  diet 
is  gradually  increased  by  the  addition  of  lean  meats,  beef,  mutton, 
poultry,  shellfish,  and  boiled  fish.  For  a  long  time,  however,  milk 
plays  an  important  role,  four  or  five  glasses  being  taken  daily. 

Weir  Mitchell  argues  that  so  sudden  a  loss  of  weight  as  occurs 
in  his  treatment  would  be  serious  were  the  patient  walking  about, 
but  when  resting  quietly  in  bed  the  danger  of  sudden  exhaustion 
of  the  heart  action  is  reduced  to  a  minimum.  His  patients  bear 
the  treatment  fairly  well,  and  are  frequently  much  pleased  with  the 
pronounced  improvement  in  appearance  and  condition  which  they 
recognise.  The  treatment  is  not  adapted  to  persons  leading  active 
lives  who  are  unable  to  relinquish  their  business  or  other  duties, 
for  it  requires  a  considerable  length  of  time  and  the  entire  aban- 
donment of  all  labour. 

THE   YEO   SYSTEM. 

The  diet  recommended  by  Yeo  is  as  follows  :  All  fats  and  animal 
food  are  to  be  strictly  limited,  and  farinaceous  and  starchy  foods 
should  be  reduced  to  a  minimum.  Sugar  must  be  entirely  prohibited, 
but  a  moderate  quantity  of  fat  is  allowed  to  secure  the  proper  dilu- 
tion and  digestion  of  the  food.  Hot  water  and  hot  aromatic  drinks 
may  be  taken  freely  in  the  intervals  between  meals,  especially  in 
gouty  cases.  He  allows  the  patient  to  drink  a  little  hock  and  still 
Moselle,  or  light  claret  with  alkaline  table  water.  Beer,  porter,  and 
sweets  of  all  kinds  are  to  be  prohibited,  and  no  spirits  should  be 
drunk  unless  for  some  special  need  as  a  tonic.  Meat  is  not  to  be 
eaten  more  than  once  a  day,  and  not  more  than  six  ounces  should  be 
taken  at  any  one  time.  The  meat  which  Yeo  allows  is  lean  beef, 
mutton,  lamb,  poultry,  game,  and  sometimes  fish  and  eggs.  Two 
lightly  cooked  or  poached  eggs  may  be  taken  once  a  day,  or  a  little 
grilled  fish.  He  allows  thoroughly  toasted  bread  in  thin  slices  and 
crackers.  Soups  in  general  and  milk,  unless  skimmed,  milk  pud- 
dings, farinaceous  puddings,  pastry,  salmon,  and  mackerel  must  all 
be  avoided.  Fresh  vegetables  and  fruits  are  allowed.  He  believes 
it  is  useless  to  attempt  to  give  rules  in  regard  to  the  actual  quantity 
of  dry  food  permitted,  because  it  must  necessarily  vary  in  accord- 
ance with  the  weight  and  strength  of  the  patient  in  each  case.  A 
quantity  of  food  which  might  constitute  an  excess  for  one  person 
would  perhaps  be  wholly  insufficient  to  support  the  strength  and 
activity  of  another. 

Later  a  full  diet  of  meat  may  be  allowed,  but  sugars  and  starches 
must  still  be  excluded  to  as  great  an  extent  as  possible.  The  patient 
may  be  taught  to  supplement  passive  exercise  by  calisthenics. 


5i2  J5IET    IN   DISEASE. 

THE  DUJARDIN-BEAUMETZ  SYSTEM. 
Dujardin-Beaumetz  believes  that  the  diets  allowed  by  Oertel  and 
Ebstein  are  too  restricted  to  support  the  body  in  a  condition  of  nor- 
mal nutrition  and  activity,  and  his  system  of  treatment  is  as  follows  : 
For  the  milder  cases  in  which  fatty  degeneration  has  not  yet  invaded 
the  heart  and  other  viscera  he  gives  half  a  pint  of  water  or  light  wine 
diluted^with  Vichy,  or  some  alkaline  effervescent  water,  with  each  of 
the  three  meals  of  the  day.  Soup  of  all  kinds  is  forbidden,  wine  or 
tea  being  recommended  instead.  If  the  gastric  juice  is  apparently 
deficient,  or  if  there  is  much  dyspepsia,  no  fluid  is  allowed  with  the 
meals,  but  the  patient  is  ordered  to  take  a  pint  of  weak  tea  without 
sugar  or  milk  two  hours  after  the  completion  of  each  meal.  No 
other  beverages  are  permitted  excepting  a  small  cup  of  black  coffee 
with  breakfast.  Soup  is  also  forbidden,  and  so  is  pastry.  He  allows 
dry  bread  in  moderation,  such  as  the  outer  part  of  Vienna  rolls,  or 
"  soup  sticks,"  which  are  chiefly  crust,  and  he  recommends  animal 
food  of  all  classes  and  several  varieties  of  fresh  vegetables  and  juicy 
fruits,  such  as  oranges.  For  breakfast  he  gives  three  quarters  of  an 
ounce  of  dry  bread,  one  and  a  half  ounce  of  meat,  and  a  cup  of  weak 
tea  or  a  glass  or  two  of  light  wine.  Lunch  is  served  at  noon,  and 
consists  of  double  the  quantity  of  bread  and  meat  permitted  at 
breakfast,  with  three  ounces  of  fresh  vegetables,  salad,  a  small  piece 
of  cheese,  and  fruit.  Eggs  may  be  substituted  for  the  meat,  or  fish 
may  be  given  at  either  breakfast  or  luncheon.  The  quantity  of  the 
several  foods  allowed  may  be  varied  slightly. 

THE  MEAT  AND  HOT-WATER  TREATMENT. 
This  method,  mainly  advocated  by  Salisbury  in  this  country,  is  a 
treatment  for  obesity  and  chronic  gastric  catarrh,  which  consists  in 
the  restriction  of  the  diet  exclusively  for  several  weeks  to  large 
quantities  of  rare  beefsteak,  and  salt  codfish  and  hot  water  for  the 
first  fortnight,  three  pounds  of  rump  steak,  one  pound  of  codfish, 
with  six  and  one  third  pints  of  hot  water,  are  subsequently  given  for 
two  or  three  weeks.  The  water  is  gradually  reduced  to  four  pints, 
and  lean  beef  and  fresh  fish  may  be  eaten  with  dry  toast  or  Zwieback, 
and  a  very  little  green  vegetable  food.  After  five  or  six  weeks  the 
hot  water  is  still  further  reduced  to  a  quart  a  day,  and  dry  crackers 
and  dry  toast  and  stale  bread  crusts,  poultry,  and  game  are  added 
to  the  diet,  and  the  patient  may  be  allowed  to  drink  hock  diluted 
with  carbonic  or  Seltzer  water.  The  hot  water,  if  desired,  may  be 
flavoured  with  fresh  lemon  juice,  and  five  or  ten  grains  of  bicar- 
bonate of  soda  are  given  twice  a  day.  This  treatment  is  found  im- 
practicable by  many  persons,  who  rebel  against  the  extreme  monot- 
ony of  it,  and  are  unable  to  eat  so  large  an  amount  of  meat  either 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


613 


with  or  without  other  food  ;  it  is  principally  adapted  to  persons  who 
are  habituated  to  overeating,  and  is  not  to  be  recommended  for  the 
majority  of  cases. 

THE   BOUCHARD   SYSTEM. 

According  to  Bouchard's  method,  the  frequent  observation  of  the 
urine  should  form  the  basis  of  the  treatment  of  obesity.  When  the 
nitrogenous  waste  is  increased  in  the  urine  he  reduces  the  allowance 
of  animal  food  ;  but  he  also  believes,  in  opposition  to  many  other 
theories  of  treatment  of  obesity,  that  the  total  quantity  of  farina- 
ceous and  fatty  food  allowed  should  be  five  times  greater  than  the 
quantity  of  animal  food,  and  asserts  that  giving  vegetable  acids  with 
the  carbohydrates  favours  the  oxidation  of  the  latter.  He  therefore 
prescribes  such  fruits  and  fresh  vegetables  as  are  rich  in  the 
potassium  salts  of  the  organic  acids.  He  forbids  the  use  of  vinegar 
and  other  acids,  which  he  claims  diminish  the  alkalinity  of  the  blood 
and  thereby  increase  the  formation  of  fat. 

The  patient's  exercise  is  also  governed  by  the  elimination  of  urea 
and  phosphates.  When  these  salts  are  present  in  excess,  he  argues 
that  the  oxidation  of  the  tissues  is  being  unduly  stimulated  ;  but  if 
they  are  not  present  in  too  large  quantity,  exercise  before  meals  is 
recommended.  A  review  of  the  principles  involved  in  this  theory 
does  not  strengthen  the  belief  in  their  value. 

The  oxidation  processes  in  the  body  are  still  too  obscure  to  en- 
able one  to  take  the  urine  as  an  absolute  criterion  of  the  conditions 
of  metabolism,  especially  in  those  cases  where  a  large  reduction  in 
the  body  weight  is  being  obtained  by  the  consumption  of  previously 
stored-up  material.  It  is  true  that  superfluous  fat,  when  fully  oxi- 
dised, leaves  the  body  in  the  form  of  carbonic  acid  and  water  from 
the  lungs,  and  in  the  form  of  water  and  carbonates  in  the  urine ; 
but  it  is  not  definitely  known  to  what  extent  this  combustion 
spares  the  proteid  materials  of  the  body  from  disintegration  and 
allows  the  animal  food  products  to  pass  directly  into  the  urine  as 
urea  or  other  nitrogenous  waste  matter.  While  the  urine  should  be 
carefully  studied  in  these  cases,  a  much  better  guide  for  the  treat- 
ment of  obesity  is  found  in  the  observation  of  other  symptoms  and 
in  the  disappearance  of  previously  existing  abnormal  conditions. 

THE  CHAMBERS  SYSTEM. 
"  Days  Regimen  for  a  Three  Weeks'  Course. — Rise  at  7.  Rub  the 
body  well  with  horsehair  gloves,  have  a  cold  bath,  take  a  short  turn 
in  the  open  air.  Breakfast  (alone)  at  8  or  8.30,  on  the  lean  of  beef 
or  mutton,  cutting  off  the  fat  and  skin,  with  dry  toast,  biscuit,  or 
oatcake,  a  tumbler  of  claret  and  water  or  tea  without  milk  or  sugar, 
or  made  in  the  Russian  way  with  a  slice  of  lemon.     Luncheon  at  i 


6i4 


DIET   IN   DISEASE. 


on  bread  or  biscuit,  Dutch  cheese,  salad,  water  cresses,  or  roasted 
apples  (without  sugar  or  cream),  hung  beef,  or  anchovies,  or  red 
herring  or  olives,  and  such  like  relishes.  Drink,  after  eating,  claret 
and  water,  unsweetened  lemonade,  or  plain  water,  in  moderation. 
Dinner  at  any  convenient  hour.  Take  no  soup,  fish,  or  pastry,  but 
plain  meat  of  any  kind  except  pork,  rejecting  the  fat  and  skin. 
Spinach,  French  beans,  or  any  other  green  vegetable  may  be  taken, 
but  no  potatoes,  made  dishes,  or  pastry.  A  jelly  or  a  lemon  water 
ice,  or  a  roast  apple  must  suffice  for  sweets  and  dessert.  Claret  and 
water  at  dinner,  and  one  glass  of  sherry  or  Madeira  afterwards. 

"  Between  meals  exercise,  as  a  rule,  in  the  open  air,  to  the  ex- 
tent of  inducing  perspiration,  must  be  taken.  Running,  when  prac- 
ticable, is  the  best  form  in  which  to  take  it." 

Chambers  also  advised  giving  liquor  potassae  with  the  proteid 
diet,  or  the  remedy  of  Dancel,  consisting  of  one  half  or  a  teaspoon- 
ful  of  sodium  bicarbonate  added  to  five  o-r  ten  grains  of  tartaric  acid 
in  a  small  tumblerful  of  water,  and  drunk  while  effervescing.  He  re- 
stricted sleep  to  seven  hours  a  day,  for  it  is  weakening  for  the  obese 
to  remain  too  long  in  bed  in  a  close  room.  Turkish  baths  were  also 
recommended.  Chambers's  further  directions  to  be  observed  by  the 
patient  to  prevent  a  possible  return  to  corpulency  were  as  follows: 
Continue  to  avoid  fat  meats,  rich  milk,  butter,  malt  liquors,  sweet 
wines,  starches,  especially  pastry  and  puddings,  and  sweet  vegeta- 
bles, such  as  parsnips  and  beets. 

The  patient  may  have  lean  beef  or  mutton,  venison,  game,  poul- 
try, boiled  fish,  poor  new  cheese,  green  vegetables  and  fresh  fruits, 
oranges,  lemons,  almonds,  roast  apples,  salads,  olives,  buttermilk, 
claret,  hock.  Bread  should  be  aerated  or  toasted.  Captain's  bis- 
cuits may  be  eaten.  Among  the  green  vegetables  which  may  be 
eaten  are  tomatoes,  celery,  stuffed  red  and  green  peppers,  radishes, 
asparagus,  artichokes,  oyster  plant,  squash,  and  spinach. 

Of  the  various  systems  above  described,  that  of  Oertel  is,  on  the 
whole,  the  best  adapted  for  the  greater  number  of  cases.  The  Eb- 
stein  treatment  diminishes  the  appetite  and  is  useful  for  robust 
patients,  but  if  there  is  enfeebled  digestion  and  weakness,  this  diet 
is  not  to  be  recommended  on  account  of  the  large  proportion  of  fat 
and  the  relatively  small  amount  of  proteid  foods.  Schweninger's 
system  has  the  disadvantage  that  although  the  withholding  of  all 
fluid  at  mealtime  lessens  the  capability  of  taking  solid  food  in  ex- 
cess, there  are  many  persons  in  whom  the  gastric  juice  is  deficient  in 
quantity,  and  its  proper  action  can  only  be  secured  by  dilution  with 
a  moderate  amount  of  fluid  during  gastric  digestion.  The  Banting 
method,  besides  being  too  rigorous  for  many,  has  the  disadvantage 
of  allowing  no  fat  to  be  eaten. 

The  essential  value  of  all  methods  of  dietetic  treatment  of  obesity 


DISEASES   ESPECIALLY   INFLUE^XED   BY   DIET.  6l$ 

is  based  upon  two  objects  to  be  attained :  First,  to  enable  the  pa- 
tient to  fully  oxidise  and  eliminate  the  fat  which  is  already  accumu- 
lated in  various  parts  of  the  body,  and,  secondly,  to  make  it  impos- 
sible for  it  to  be  reformed. 

From  what  has  been  said  already  concerning  the  cause  and  nature 
of  obesity  in  relation  to  the  different  classes  of  cases,  it  follows  that 
no  one  system  of  treatment  is  applicable  in  every  instance.  Discre- 
tion must  be  used  in  individual  cases  and  the  effect  of  any  treat- 
ment should  be  observed  from  day  to  day,  especial  care  being  taken 
that  the  patient  while  losing  flesh  does  not  at  the  same  time  lose  in 
strength  to  a  degree  which  may  become  dangerous.  In  all  cases 
frequent  and  thorough  examinations  should  be  made  of  the  heart 
action,  the  circulation,  and  the  urine. 

The  favourite  baths  which  are  resorted  to  in  Europe  for  the 
treatment  of  obesity  are  Carlsbad  and  Marienbad,  but  there  are 
many  others. 

"ANTI-FAT"   REMEDIES. 

A  host  of  quack  nostrums  are  offered  to  a  credulous  public  un- 
der the  claim  that  they  reduce  corpulency.  Some  of  them  have 
achieved  reputation  because  while  they  are  taken  the  patient  is  also 
induced  to  regulate  his  diet;  others  merely  because  they  have  de- 
stroyed the  appetite  or  digestion  and  have  made  it  impossible  to  eat 
too  much  food.  But  the  whole  lot  of  "  reduction  pills,"  concentrated 
salts  and  purges,  extracts  of  phytolacca  berries,  Fucus  vesiculosus^ 
and  other  so-called  "  specifics  "  for  reduction  of  obesity  cannot  be 
too  strongly  condemned  as  thoroughly  unscientific,  if  not  positively 
harmful  or  dangerous,  as  many  of  them  are. 

It  cannot  be  expected  that  any  chemical  remedy  can  control  the 
complex  processes  involved,  and  the  substances  which  are  in  exten- 
sive use  by  credulous  persons  for  this  purpose  diminish  the  appetite, 
impair  the  digestion,  and  at  the  same  time  seriously  interfere  with 
nutrition. 

There  is  no  drug  or  remedy  known  which  acts  specifically  either 
in  retarding  fat  formation  or  in  causing  its  destruction  in  the  body, 
and  when  any  such  remedy  appears  to  have  that  effect,  it  is  acting 
indirectly  by  a  general  lowering  of  vitality.  The  dietetic  treatment 
of  obesity  is  the  only  rational  one,  and  when  that  fails  it  is  hazard- 
ous to  employ  other  means. 

Diet  for  Leanness. 

The  foods  which  tend  to  produce  fat  in  the  body  are  chiefly 
sugars  and  starches.  Eating  fat  in  excess  does  not  necessarily  cause 
fat  to  accumulate  in  the  system,  for  it  may-  be  completely  oxidised. 

To  increase  the  albuminous  constituents  of  the  body  without  the 
accession  of  fat,  a  diet  should  be  ordered  in  which  proteid  food  pre- 


5i6  DIET    IN   DISEASE. 

dominates,  with  a  moderate  allowance  of  carbohydrates.  To  in- 
crease the  body  fat,  however,  the  proportion  of  carbohydrate  should 
considerably  exceed  the  proteid  food  and  a  little  fat  should  be  added. 
In  seeking  to  remedy  excessive  leanness  by  dietetic  treatment  it 
is  obviously  necessary  to  first  ascertain,  if  possible,  its  cause.  It 
may  be  due  to  the  use  of  improper  food,  to  erroneous  habits  of  eat- 
ing, bad  cooking,  maldigestion  or  malassimilation,  overwork  and  nerv- 
ous exhaustion,  disease  of  the  various  organs  connected  especially 
with  nutrition,  and  besides  these  and  other  causes  there  are  some 
persons  in  whom  leanness  seems  to  be  constitutional.  They  may 
enjoy  excellent  health,  but  are  always  so  thin  as  to  be  the  subject 
of  comment.  No  diet  seems  to  have  much  effect  in  increasing  their 
weight.  Another  class  of  persons  are  those  whose  weight  is  con- 
stantly fluctuating  and  whose  annual  variation  is  as  much  as  ten  or 
even  twenty  pounds.  In  winter,  in  town  life,  when  overworked,  wor- 
ried, or  oppressed  with  mental  strain,  they  lose  weight  rapidly,  and 
in  summer,  in  a  brief  holiday  in  the  country,  with  little  to  do  but  eat 
and  sleep,  they  gain  at  the  rate  of  two  or  three  pounds  a  week.  This 
is  true  more  often  of  those  whose  general  tendency  is  towards  obesity 
rather  than  towards  leanness. 

It  is  almost  hopeless  to  attempt  to  remedy  obstinate  leanness  by 
diet  unless  other  favouring  conditions  can  be  secured.  First  among 
these  is  entire  freedom  from  mental  strain,  and  of  almost  equal  im- 
portance is  abundant  and  regular  sleep.  A  warm  climate  and  inac- 
tive life  favour  increase  in  weight.  In  most  "respects  the  diet  for 
leanness  must  be  the  reverse  of  that  for  obesity,  as  would  be  natu- 
rally expected,  and  in  prescribing  starchy  foods  it  must  be  remem- 
bered that  the  leanness  is  often  caused  solely  by  an  entire  inability 
to  digest  amylaceous  or  saccharine  material  owing  to  "  nervous  dys- 
pepsia," gastric  catarrh,  etc.  These  conditions  should  receive  careful 
treatment  on  the  lines  recommended  on  pages  500  and  504.  By  a 
little  care  it  will  often  be  found  possible  to  find  some  forms  of 
starches  which  can  be  digested.  It  is  a  good  rule  in  such  cases  to 
give  the  cereals  or  vegetables  at  one  meal  and  meat  at  another,  so 
that  articles  involving  different  rates  and  organs  of  digestion  do  not 
interfere  with  each  other.  All  bread  should  be  stale  or  toasted. 
Crackers  and  Zwieback  may  be  allowed.  As  a  rule  such  patients  can 
be  made  to  digest  starches  before  they  can  sugars — oatmeal  will  be 
better  digested  without  sugar,  and  a  cup  of  sweetened  coffee  with  a 
meal  of  starchy  foods  may  produce  flatulency  which  lasts  for  hours. 

When  the  digestive  organs  admit,  the  following  articles  may  be 
prescribed  in  the  diet  for  leanness  : 

Abundant  fat  meats,  butter,  cream,  milk,  cocoa,  and  chocolate. 
Bread,  potatoes,  legumes,  well-cooked  cereals,  especially  oatmeal  and 
corn  meal,  farinaceous  puddings  with  sugar  and  cream,  cake,  sweets. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  617 

sirup,  honey,  sweet  wines,  port,  porter,  stout,  ales,  and  beer.      Malt 
preparations  of  all  sorts  are  also  useful.     Sweet  fruits  may  be  eaten. 
To  be  avoided  are  pickles,  acids,  condiments,  much  bulk  of  green 
vegetables,  and  strong  liquors. 

Diet  in  Acute  Rheumatism. 

Causation. — It  has  not  been  proved  that  any  special  articles  of 
diet  lead  to  the  development  of  rheumatism,  although  indulgence 
in  sweets,  starchy  foods,  and  malt  liquors  is  sometimes  held  respon- 
sible for  it.  Poor  living  seems  to  favour  the  attacks.  In  regard  to 
this  point  Captain  Woodruff,  U.  S.  Army,  says: 

"  The  enormous  number  of  cases  of  rheumatism  occurring  during 
the  rebellion  and  since  the  rebellion  in  veterans  may  not  be  entirely 
due  to  the  exposures,  as  popularly  supposed.  These  men  were  hard- 
ened to  exposure  and  should  not  have  had  more  rheumatism  than 
hunters,  trappers,  and  the  aboriginal  Indians.  The  limited,  often 
insufficient,  ration  and  the  absence  of  fresh  articles  may  have  been 
one  of  the  factors  at  work." 

Dietetic  Treatment. — While  the  fever  lasts  and  other  symp- 
toms are  acute,  such  as  pain  and  swelling  of  the  joints,  the  patient 
should  be  put  upon  a  fluid  diet.  The  majority  of  cases  do  best  at 
this  time  with  an  exclusive  milk  or  bread-and-milk  diet.  Those  pa- 
tients who  cannot  take  milk,  however,  may  be  allowed  soups  and 
broths  flavoured  with  vegetable  extracts,  chicken  tea,  milk  toast, 
barley  or  oatmeal  gruel,  clam  broth. 

Thirst  is  often  a  prominent  symptom,  especially  if  there  be  much 
fever,  and  it  is  advisable  for  the  patient  to  drink  fluid  freely  to  assist 
in  washing  out  the  waste  products  from  the  body.  Lemonade  and 
slightly  acid  drinks  of  various  kinds,  such  as  dilute  phosphoric  acid 
or  the  effervescent  mineral  waters,  are  recommended.  Boiled  milk 
and  Seltzer  or  Vichy  may  be  drunk,  or  oatmeal  or  barley  water 
flavoured  with  lemon.  Alcohol  should  be  avoided  while  the  acute 
symptoms  last,  unless  the  complication  of  inflammation  of  the  endo- 
cardium or  pericardium  enfeebles  the  heart  action  to  such  a  degree 
as  to  make  stimulation  necessary.  If  convalescence  is  prolonged 
and  anaemia  is  considerable,  alcohol  may  be  given  as  a  tonic  two  or 
three  times  a  day  in  the  form  of  a  glass  of  claret  or  Burgundy  (one 
to  two  ounces),  or  diluted  whisky. 

During  convalescence  the  appetite  is  not  usually  vigorous,  and  it 
is  not  necessary  to  urge  the  taking  of  much  food  at  first.  The  diet 
should  be  principally  farinaceous,  but  not  saccharine. 

Such  articles  may  be  given  as  rice  (plain  or  spiced),  arrowroot,  oat- 
meal, corn  meal,  semolina,  wheaten  grits,  panada,  milk  toast,  simple 
unsweetened  puddings,  "meagre"  soup,  wine  jelly,  blancmange, 
malted  foods. 


6,8  DIET   IN   DISEASE. 

The  return  to  solid  diet  should  be  gradual,  and  for  a  long  time 
the  patient  should  abstain  from  eating  meats  as  well  as  from  pastry 
and  sweets.  Fagge  states  that  no  meat  or  fish  should  be  allowed  for 
at  least  a  week  after  subsidence  of  the  fever  and  acute  symptoms, 
or,  better,  for  a  fortnight,  and  many  believe  that  beef  tea  is  harmful. 
Meat  can  undoubtedly  induce  a  relapse. 

When  convalescence  becomes  established,  eggs,  fish,  oysters,  and 
the  white  meat  of  broiled  or  roasted  chicken  may  be  given,  and  one 
or  two  such  vegetables  as  asparagus,  spinach,  or  stewed  celery,  with 
a  baked  apple  or  fresh  fruit,  but  sweets  and  alcohol  should  long  be 
withheld. 

The  patient  should  be  fed  often,  having  one  or  two  extra  lunches 
during  the  day,  for  anaemia  is  apt  to  prevail  for  some  time,  and 
abundant  nutriment  is  required. 

Diet  in  Chronic  Rheumatism. 

In  the  dietetic  treatment  of  chronic  rheumatism,  especially  if  the 
patient  is  anaemic,  animal  food  cannot  be  excluded,  but  the  basis  of 
the  diet  should  be  farinaceous  food  with  a  few  fresh  green  vegeta- 
bles. Fish,  eggs,  and  fowl  may  be  eaten,  but  dark  meat  is  not  de- 
sirable. Sweets  and  alcoholic  beverages  should  be  omitted  from  the 
menu,  and  all  foods  should  be  plainly  cooked  and  eaten  in  moderation. 

Rheumatoid  Arthritis. 

Causation. — Rheumatoid  arthritis  is  a  chronic  disease  in  which 
the  joints  of  the  body,  and  particularly  those  of  the  extremities,  are 
affected.  The  disease  may  originate  independently,  or  it  may  ap- 
pear in  connection  with,  or  as  a  sequel  to,  gout,  acute  articular  rheu- 
matism, or  gonorrhoeal  rheumatism.  The  alterations  in  joint  struc- 
tures are  produced  mainly  by  impoverished  nutrition,  and  the  disease 
is  especially  one  of  advanced  life,  occurring  in  persons  in  whom 
various  evidences  of  senility  have  begun  to  appear.  The  structural 
changes  in  the  joints  involve  proliferation  of  the  cellular  elements  of 
the  cartilages,  with  thickening  and  erosion  and  with  the  production 
of  osteophytes.  In  mild  cases  there  is  not  much  impairment  of  gen- 
eral health.  In  severer  cases  the  patient  is  confined  to  the  house 
and,  on  account  of  pain  or  immobility  of  the  joints,  is  unable  to  take 
ordinary  exercise.  Digestion  and  nutrition  suffer  considerably  in 
consequence. 

Dietetic  Treatment. — Since  the  disease  is  one  of  debility  and 
impoverished  nutrition,  it  follows  that  a  low  diet  is  harmful  and  a 
nourishing  diet,  with  increased  frequency  of  meals,  is  desirable. 
James  Stewart  says:  "The  practice  of  limiting  the  amount  of  nitrog- 
enous food  is  not  to  be  commended.  Provided  there  is  no  gen- 
eral   or   local  contraindication,   the  patient  should   be  directed   to 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


619 


take  as  much  nitrogenous  food  as  can  be  digested  with  facility." 
And  Garrod  wrote  :  "  I  consider  it  of  the  utmost  importance  through- 
out the  whole  course  of  the  disease  to  support  the  system  and  to 
allow  the  patient  as  nourishing  a  diet  as  he  is  capable  of  properly 
digesting."  Good  roast  beef,  beefsteak,  mutton,  fowl,  fish,  eggs,  and 
milk  may  be  eaten. 

Mustard  and  horseradish  are  recommended  by  Lyman  as  useful 
adjuncts  to  the  diet  on  account  of  the  sulphur  which  they  contain. 

Alcoholic  beverages  taken  with  meals  in  proper  moderation  are 
beneficial  for  their  strengthening  and  tonic  effect,  and  bitter  tonics 
may  be  combined  with  them  to  advantage.  The  objection  which 
exists  to  the  use  of  alcohol  in  gout  and  acute  rheumatism  does  not 
apply  with  such  force  in  this  disease.  Malt  liquors  may  be  given, 
such  as  ale  or  stout,  and  it  is  often  desirable  to  prescribe  a  good 
Burgundy,  port,  or  sherry.  If  it  is  well  borne  by  the  stomach,  cod- 
liver  oil  should  be  given  in  teaspoonful  doses,  an  hour  after  meals, 
three  times  a  day.  It  is  an  excellent  food  in  this  disease,  and  its  use 
should  be  long  continued.  Other  forms  of  fat  may  be  used,  such  as 
butter,  cream,  or  bone  marrow,  olive  oil,  etc. 

When  acute  exacerbations  occur  the  quantity  of  food  and  stimu- 
lants should  be  reduced,  but  otherwise  it  is  important  that  the  diet 
should  always  be  ample. 

Intractable  cases  do  well  to  try  the  effect  of  a  course  of  treat- 
ment at  the  hot  springs  of  Virginia,  Arkansas,  or  Banff. 

Gout. 

Gout  is  a  constitutional  disease  which  has  local  manifestations 
appearing  from  time  to  time  in  the  joints,  especially  the  metacarpo- 
phalangeal articulation  of  the  great  toe,  but  it  must  be  remembered 
that  the  gouty  diathesis  is  a  condition  which  once  acquired  may  exist 
for  years,  producing  many  other  and  more  serious  symptoms  or 
structural  changes  in  the  body  than  the  local  inflammation  of  one  or 
more  joints. 

Causation. — Gout  has  been  defined  as  a  condition  dependent 
upon  disturbed  retrograde  metamorphosis  of  the  nitrogenous  in- 
gredients of  the  food — a  high-sounding  phrase,  which,  it  must  be 
confessed,  carries  with  it  very  little  genuine  explanation  of  the  nu- 
tritive processes  involved.  Whatever  may  be  the  theories  in  regard 
to  the  production  of  an  attack  of  acute  gout,  it  is  universally  ad- 
mitted that  careful  regulation  of  the  diet  is  the  most  important 
factor  in  its  treatment.  Gout  and  the  various  conditions  allied  to  it 
are  dependent  upon  retention  in  the  blood  or  other  fluids  of  the 
body  of  forms  of  waste  matter  which  nor^mally  should  be  oxidised 
and  completely  converted  into  the  soluble  materials  which  are 
excreted   in    the   urine.     For  some   reason    the   oxidation  of  waste 


620  DIET    IN   DISEASE. 

matter  is  suspended,  and,  as  a  result,  a  variety  of  intermediate  prod- 
ucts of  imperfect  solubility  may  be  deposited  in  the  joints  or  tissues 
of  the  body.  The  active  manifestations  of  gout  are  due  to  an  accu- 
mulation of  insoluble  urates  in  the  joints.  In  conditions  which 
are  closely  allied  to  gout,  such  as  the  uric-acid  diathesis,  there  is 
a  deposition  of  crystals  of  uric  acid  in  some  portion  of  the  urin'ary 
tract  or,  in  other  conditions,  deposits  of  insoluble  cholesterin  are 
formed  from  the  bile  and  accumulate  as  gallstones  in  the  gall 
bladder. 

The  direct  relation  existing  between  uric  acid  and  gout  has  been 
most  exhaustively  investigated  by  Garrod,  and  this  relation  may  be 
briefly  summarised  as  follows  :  First,  the  gouty  diathesis  is  associated 
with  a  more  or  less  constant  excess  of  uric  acid  in  the  blood ;  sec- 
ondly, the  quantity  of  uric  acid  normally  present  in  the  urine  is  di- 
minished by  at  least  one  half  during  a  severe  attack  of  gout,  and 
increases  beyond  the  normal  as  soon  as  the  acute  symptoms  subside. 
An  acute  attack  of  gout  is  therefore  preceded  by  accumulation  of 
uric  acid  in  the  blood,  which  is  a  substance  that  in  itself  represents 
incomplete  combustion  of  nitrogenous  waste  material  in  the  body. 
The  retention  of  this  form  of  waste  in  considerable  quantity  proves 
markedly  irritating  to  the  nervous  and  other  organs  of  the  body. 

Sir  Dyce  Duckworth  writes:  "We  perhaps  come  nearer  a  com- 
plete understanding  of  this  matter  if  we  regard  as  present  in  the 
gouty  a  peculiar  incapacity  for  nornial  elaboration  within  the  whole 
body,  not  merely  in  the  liver  or  in  one  or  two  organs,  of  food, 
whereby  uric  acid  is  formed  at  times  in  excess,  or  is  incapable  of 
being  duly  transformed  into  more  soluble  and  less  noxious  products," 
and  he  agrees  with  Ralfe  that  the  failure  to  complete  the  metabolism 
of  uric  acid  is  dependent  primarily  upon  disturbed  innervation. 

In  referring  to  the  habit  of  overeating,  Sir  H.  Thompson  says 
that  in  early  life  it  may  give  rise  to  occasional  attacks  of  biliousness, 
but  after  the  first  half  of  life  has  been  spent  the  remaining  half  may 
be  affected  in  a  different  way,  and  "  recurring  attacks  of  gout  per- 
form the  same  duty,  or  nearly  so,  at  this  period  of  life  that  bilious 
attacks  accomplished  in  youth." 

On  the  other  hand,  in  persons  who  are  subject  to  attacks  of  gout 
starvation  may  bring  it  on  (Senator),  and  "poor  man's  gout"  is  by 
no  means  a  disease  induced  by  plenty. 

Sugar  eaten  in  excess  is  not  of  itself  a  direct  cause  of  gout,  but 
sweets  combined  with  certain  other  foods,  such  as  certain  fruits 
and  wines,  will  precipitate  an  attack  in  a  gouty  subject  with  cer- 
tainty. According  to  the  view  of  Sir  Dyce  Duckworth,  it  is  the  com- 
bination of  sugar  with  vegetable  acids  which  is  especially  injurious. 

Sugar,  under  some  conditions  of  fermentation  in  the  stomach 
and  intestines,  forms  lactic  acid,  which  is  capable  of  splitting  so  as 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  62 1 

to  produce  carbon  dioxide,  which,  according  to  Ralfe,  forms  acid 
salts  of  sodium  and  potassium  from  their  neutral  compounds. 

Lack  of  exercise  is  often  assigned  as  a  cause  for  gout,  and  with 
many  persons  it  is  true  that  outbreaks  of  gout  may  be  intensified  in 
this  way ;  but  it  is  not  uncommon  for  the  disease  to  affect  men  who 
lead  lives  of  considerable  activity  or  who  practise  athletics,  but  who 
at  the  same  time  consume  large  quantities  of  nitrogenous  food.  By 
free  perspiration  the  amount  of  fluid  present  in  the  blood  is  reduced 
and  the  solids  become  both  relatively  and  absolutely  increased, 
making  it  difficult  or  impossible  for  them  all  to  become  thoroughly 
oxidised. 

Symptoms. — The  most  distinctive  symptoms  of  gout  are  the 
local  joint  manifestations  of  pain,  swelling,  redness,  and  tenderness. 
These  symptoms  usually  occur  together  in  an  acute  attack,  but  either 
one  may  occasionally  be  absent.  Other  symptoms  may  appear  from 
time  to  time,  such  as  disorders  of  the  mucous  membranes,  espe- 
cially of  the  stomach  and  bowels;  a  tendency  for  the  catarrhal 
affections  of  the  mucous  membranes  of  the  respiratory  passages; 
chronic  endarteritis  ;  alterations  in  the  composition  of  the  urine;  and 
various  forms  of  irritation  of  the  nervous  system  and  the  skin. 

Children  who  inherit  the  gouty  diathesis  are  very  apt  to  present 
some  one  or  more  of  this  group  of  symptoms,  especially  neuralgic 
pains,  digestive  disturbances,  and  skin  diseases,  which  appear  at  an 
early  age  and  long  before  the  gout  is  fully  developed  with  typical 
localised  joint  symptoms.  The  symptoms  connected  with  this  diath- 
esis are  believed  to  arise  from  obscure  alterations  in  the  composi- 
tion of  the  blood  which  are  more  or  less  remediable  by  dietetic  treat- 
ment. 

Preventive  Treatment. — The  prophylactic  treatment  of  gout 
in  those  who  inherit  a  constitutional  predisposition  to  the  disease  is 
very  important.  From  birth  onward  the  children  of  gouty  parents 
should  be  abstemious,  have  the  diet  carefully  balanced  so  that  neither 
animal  nor  vegetable  food  predominates  in  great  excess.  As  the  child 
grows  older,  confectionery  and  sweets  in  general  should  be  avoided, 
especially  with  other  food  or  at  the  conclusion  of  meals,  as  well  as 
alcohol  in  every  form.  In  youth  all  varieties  of  beer,  ale,  cider,  etc., 
are  particularly  injurious.  Tea  and  coffee,  if  allowed  at  all,  should 
be  taken  in  moderation,  and  some  persons  can  often  precipitate  a 
violent  attack  of  gout  by  a  single  glass  of  champagne  or  sweet  wine. 

If  they  are  accustomed  to  the  use  of  alcoholic  beverages  and  it  is 
impossible  for  them  to  go  without  them,  those  which  are  least  injuri- 
ous are  a  dry  white  wine  or  old  Bordeaux,  but  all  wines  containing 
sugar  or  tannin  must  be  absolutely  prohibited. 

Cyr  says:  "If  a  glass  of  beer,  spirits,  or  wine  is  habitually  fol- 
lowed by  pain  in  a  joint  or  nerve  it  is  gouty." 


522  DIET    IN    DISEASE. 

Theory  of  Dietetic  Treatment. — An  important  question  in  re- 
gard to  the  theory  of  gout  is  still  under  discussion — namely,  whether 
the  increased  quantity  of  uric  acid  is  to  be  attributed  to  overproduction 
or  merely  to  faulty  elimination.  It  is  conceivable  that  the  fluids  of 
the  body,  by  becoming  less  alkaline  than  normal,  may  fail  to  retain 
the  salts  of  uric  acid  in  solution,  and  are  consequently  precipitated  in 
the  joints  and  elsewhere.  The  matter  is  of  vital  importance  in  the 
selection  of  the  proper  diet  for  gouty  patients.  If  the  disease  is 
caused  merely  by  imperfect  oxidation  of  nitrogenous  food,  the  indi- 
cation is  clearly  to  diminish  the  quantity  of  such  food  ingested  and 
to  promote  oxidation  by  exercise  and  fresh  air.  If,  on  the  other 
hand,  oxidation  processes  are  fairly  normal,  but  the  blood  is  in  a 
morbid  state  in  which  it  becomes  less  alkaline  than  normal  and  loses 
its  solvent  power  upon  the  nitrogenous  waste  matters,  it  is  possible 
that  other  causes  may  be  responsible  for  the  condition  produced. 
Albumins  contain  both  sulphur  -and  phosphorus  which  are  destined 
to  leave  the  body  in  the  form  of  salts  of  sulphuric  and  phosphoric 
acids  respectively.  If  these  acids  fail  to  be  wholly  neutralised  while 
yet  in  the  blood  they  will  lessen  its  alkalinity,  and  in  this  way  over- 
indulgence in  albuminous  food  by  furnishing  an  excess  of  sulphur 
and  phosphorus  may  diminish  the  alkalinity  of  the  blood  and  produce 
uricsemia.  This  explains  why  the  use  of  alkaline  waters  is  so  gener- 
ally beneficial  in  gout  and  lithaemia.  Such  fluids  assist  in  regulating 
the  normal  alkaline  reaction  of  the  blood.  This  is  the  line  of  argu- 
ment which  has  been  advanced  by  many  physiological  chemists,  and 
it  applies  in  equal  force  to  the  method  of  formation  of  renal  calculi 
and  gravel.  The  acidity  of  the  urine  is  increased  by  a  meat  diet  and 
reduced  by  a  vegetable  diet.  With  the  latter  it  may  even  become 
strongly  alkaline.  Whether  we  adopt  the  theory  of  deficient  oxida- 
tion or  of  diminished  alkalinity  of  the  blood,  the  indications  for  die- 
tetic treatment  of  gout  are  the  same — namely,  reduction  of  proteid 
food  and  increase  of  vegetable  food.  It  does  not  follow  that  albu- 
minates must  be  entirely  given  up  in  all  cases  of  gout,  but  they 
should  be  so  restricted  that  the  normal  balance  of  the  metabolism  of 
the  blood  shall  be  restored.  It  will  be  found  necessary  for  those 
who  live  luxurious  and  idle  or  sedentary  lives  to  give  up  nitrogenous 
food  absolutely  while  those  who  are  accustomed  to  take  active  mus- 
cular exercise  may  be  allowed  animal  food  in  very  moderate  quanti- 
ties once  a  day. 

Dietetic  Treatment. — Although  no  one  food  is  invariably  in- 
jurious at  all  times,  it  is  almost  universally  agreed  that  for  the  gouty 
fat  and  nitrogenous  food  should  be  greatly  restricted  and  saccharine 
food  should  be  entirely  prohibited. 

It  may  be  established  as  a  general  rule  that  the  diet  of  the  gouty 
should  consist  principally  of  easily  digested  fresh  green  vegetables 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


623 


and  sometimes  certain  fruits,  in  addition  to  which  a  moderate  quan- 
tity of  lean  meat  (beef,  lamb,  and  mutton)  may  be  eaten  to  prevent 
the  necessity  of  taking  an  excessively  bulky  diet,  which  in  order  to 
furnish  sufficient  nitrogen  for  the  needs  of  the  body  would  unduly 
tax  the  digestive  system.  Fruit  is  less  apt  to  disagree  if  taken  by 
itself,  not  with  sugar  or  other  food. 

It  is  a  serious  mistake  to  prescribe  any  treatment  for  the  gouty 
which  tends  to  lower  the  general  vitality  of  the  system  too  much. 
The  diet,  therefore,  must  be  so  adjusted  as  to  secure  the  right  pro- 
portion of  the  different  classes  of  foods.  Atonic  cases  require  a  gen- 
erous diet  with  more  proteids. 

Gout  is  often  combined  with  excessive  corpulency,  and  when  this 
is  the  case  no  chronic  disease,  with  the  exception,  perhaps,  of  dia- 
betes, requires  more  strict  regulation  of  the  diet  and  hygiene  of  the 
patient.  While  it  is  undesirable  to  allow  animal  food  in  large  quan- 
tities in  gout,  it  is  also  true  that  vegetables  are  fattening,  and  if  the 
diet  is  too  restricted  in  both  these  classes  of  foods  the  obese  patient 
suffers  from  lack  of  nutrition,  and  digestion  becomes  still  further  im- 
paired in  consequence. 

The  theory  has  been  held  that  but  little  fat  should  be  eaten  by 
the  gouty,  for  it  fixes  oxygen  which  would  otherwise  complete  the 
oxidation  of  albuminates,  and  hence  it  favours  accumulation  of  pro- 
teid  waste  products.  On  the  other  hand,  it  has  been  shown  that  the 
accumulation  of  uric  acid  is  not  due  to  lessened  oxidation,  but  that 
it  is  increased  by  proteid  metabolism,  and  its  elimination  by  the  kid- 
neys is  actually  promoted  by  fats.  Clinically,  however,  it  is  found 
best  to  control  the  use  both  of  albumins  and  fats. 

Sugars  and  gelatinous  material,  like  fats,  all  tend  to  retard  the 
complete  combustion  of  proteid  food,  and  the  latter  therefore  remains 
in  an  imperfectly  oxidised  condition  which  may  give  rise  to  uricaemia. 
The  combination  of  the  latter  classes  of  foods,  therefore,  is  particu- 
larly injurious  in  gout.  On  the  other  hand,  Ebstein  favours  the  use 
of  fat  in  moderation,  on  the  ground  that  it  appeases  the  appetite  and 
makes  the  consumption  of  a  large  quantity  of  carbohydrates  unneces- 
sary. If  fat  is  allowed  at  all  in  the  diet,  it  is  best  to  give  it  in  very 
small  amount;  otherwise  it  interferes  with  the  local  digestion  in  the 
stomach  and  tends  to  aggravate  the  dyspepsia  which  is  so  common 
in  gouty  subjects.  It  will  be  better  borne  in  those  cases  which  are 
not  complicated  by  a  tendency  to  obesity. 

In  the  dietetic  management  of  gout  in  robust  subjects  it  is  of 
quite  as  much  importance  to  reduce  the  quantity  of  food  consumed 
as  to  restrict  the  variety. 

Robust  gouty  patients  must  be  made  t.o  restrain  a  too  vigorous 
appetite,  and  especially  the  eating  of   all  sorts  of  foods   between 
meals,  for,  as  Balfour  says  (The  Senile   Heart),  "there  is  nothing 
42 


624 


DIET    IN    DISEASE. 


SO  destructive  of  gastric  comfort  as  the  continual  pecking  induced 
by  gouty  bulimia." 

They  should  never  be  allowed  to  eat  to  complete  satiety  at  meals, 
and  all  rich  sauces,  pastry,  and  strong  condiments  and  fried  food 
should  be  avoided.  The  majority  of  gouty  patients  have  been  in  the 
habit  for  a  long  time  of  eating  too  much  meat,  and  some  of  them 
of  partaking  too  freely  of  carbohydrates.  Overeating  is  almost  as 
bad  for  patients  as  drinking  too  much.  "Gout  is  evidence  of  an 
overfed,  overworked,  and  consequently  clogged  machine  "  (Osier). 
As  Bence  Jones  says :  "  It  is  best  to  allow  a  minimum  of  albu- 
minous food  to  produce  the  least  amount  of  uric  acid  and  a  mini- 
mum of  carbohydrates,  in  order  to  give  the  uric  acid  formed  op- 
portunity to  be  oxidised  as  much  as  possible." 

When  an  acute  exacerbation  of  gout  occurs  it  is  necessary  to 
curtail  all  variety  in  diet,  and  put  the  patient  upon  light  farinaceous 
food  with  abundant  diluents,  alkaline  waters,  weak  tea.  Gruels  of 
sago,  arrowroot,  or  barley  may  be  given,  with  bread  or  toast. 
When  the  fever  subsides  and  the  acute  symptoms  abate,  bouillon, 
clam  juice,  simple  broths  made  of  lean  mutton  or  chicken  with  rice, 
may  be  allowed.  Later,  a  little  whitefish  or  breast  of  chicken. 
Meat  should  be  given  only  when  absolutely  necessary  for  nourish- 
ment, for,  as  Garrod  says  of  it,  "  everything  beyond  what  is  abso- 
lutely required  for  the  nourishment  of  the  body  only  feeds  the 
disease." 

Sir  Dyce  Duckworth's  treatment  of  the  acute  disease  is  briefly  as 
follows:  He  recommends  such  substances  as  rice,  bread,  arrowroot, 
sago,  tapioca  pudding,  and  semolina.  He  allows  milk,  weak  tea,  and 
infusion  of  cocoa  nibs.  Later,  chicken  broth  may  be  given,  fol- 
lowed by  fish  and  a  mealy  roasted  potato.  No  meat  should  be  given 
until  all  acute  symptoms  are  over,  and  then  it  should  be  allowed 
but  once  a  day.  Elderly  persons  may  have  a  little  dilute  whisky  or 
brandy,  not  to  exceed  two  ounces /^r  diem.  He  also  favours  the  use 
of  hot  water,  as  in  the  treatment  of  dyspepsia,  but  discountenances 
the  eating  of  fruits,  especially  with  sugars. 

When  the  acute  attack  subsides  and  chronic  gout  supervenes 
Garrod  replaces  the  farinaceous  diet  gradually  by  fruit,  fish,  fowl, 
and  finally  by  meat,  but  any  dishes  containing  free  acids  or  sweets 
are  liable  to  cause  a  relapse. 

DIET  FOR  THE  GOUTY  DIATHESIS  AND  CHRONIC  GOUT. 
In  the  following  dietary  a  liberal  variety  of  foods  will  be  found, 
some  of  which  may  be  selected  and  changed  from  time  to  time  ac- 
cording to  need  in  the  intervals  between  the  exacerbations  or  in 
chronic  gout.  Should  an  acute  attack  occur  at  any  time  in  the 
course  of  the  disease,  the  diet  must  be  at  once  restricted,  as  described 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  625 

above.  The  number  of  dishes  allowed  at  any  one  meal  should  be 
few.  In  dealing  with  any  case  of  chronic  gout  for  the  first  time  it 
is  injudicious  to  make  radical  changes  in  the  diet  too  suddenly. 

Soups. — Soup  should  be  free  from  all  fat,  and  it  is  better  made 
of  vegetables  than  meat,  and  purees  of  potatoes,  celery,  etc.,  may  be 
recommended.  If  the  taste  of  meat  is  desired,  as  suggested  by 
Yeo,  it  is  best  imparted  to  the  soup  by  one  of  the  meat  extracts 
which  contain  simply  the  highly  flavoured  extractive  matter  without 
contributing  to  the  bulk  of  proteid  food.  A  teaspoonful  or  two  of 
Valentine's  meat  juice  or  Liebig's  extract  of  meat  in  a  half  pint  of 
vegetable  soup  accomplishes  this  result. 

Milk. — Milk  wholly  disagrees  with  some  gouty  persons,  but  in 
those  who  digest  it  well,  if  it  be  not  too  rich  in  fat  or  if  it  is  taken 
skimmed  or  diluted,  it  forms  an  excellent  food.  Many  are,  however, 
opposed  to  its  use  in  any  form,  even  when  rendered  alkaline  by  the 
admixture  of  alkaline  waters  or  a  few  grains  of  bicarbonate  of 
sodium.  Yeo  gives  a  small  salt-spoon  full  each  of  potassium  bi- 
carbonate and  common  salt  in  a  breakfast-cup  full  of  hot  milk 
and  water.  Others  give  it  with  warm  water.  The  attempt  has  been 
made  to  place  gouty  patients  upon  an  exclusive  milk  diet.  This 
sometimes,  but  not  often,  aids  those  who  are  robust  and  young,  but 
it  is  injurious  to  older  patients. 

Cheese,  being  a  concentrated,  proteid  food,  should  not  be  eaten. 

Eggs. — Eggs  should  be  avoided  as  a  rule,  on  account  of  the 
excessive  proportion  of  fat  and  albumen  and  lecithin  which  they 
contain. 

Garrod  allows  eggs  and  bacon  for  breakfast,  and  Ralfe  recom- 
mends an  occasional  "  savoury  omelet."  Eggs  cooked  with  milk  and 
custard  puddings  (unsweetened  except  with  saccharin)  may  some- 
times prove  harmless,  but  Senator  is  opposed  to  them  on  account 
of  the  fat  and  lecithin  which  they  contain. 

Shellfish  and  Crustaceans.— The  soft  part  of  oysters  and 
clams  may  be  eaten,  but  crabs,  lobsters,  and  shrimps  may  not  be 
allowed,  least  of  all  in  salads. 

Fish. — Some  writers  maintain  that  fish  should  constitute  the 
chief  nitrogenous  food,  while  others  prescribe  it  very  moderately,  if 
at  all. 

Broiled  or  boiled  fish,  such  as  bluefish,  whitefish,  bass,  shad,  are 
permissible  occasionally  for  variety,  but  fish  having  firm  flesh  and 
those  which  contain  considerable  fat  are  not  good.  Salmon,  mack^ 
erel,  halibut,  codfish,  should  therefore  be  avoided,  although  Garrod 
allows  salmon  served  with  salt  and  Cayenne,  but  without  sauce. 
Rich  sauces  must  not  be  eaten  with  fish  qr  salads.  In  lieu  of  them, 
a  simple  dressing  of  an  infusion  of  aromatic  herbs  and  pepper, 
or  a  plain  bread  sauce,  may  be  employed. 


526  I^IET   IN    DISEASE. 

Smoked  and  pickled  fish  are  forbidden.  Fish  roe,  such  as  shad 
roe  and  caviare,  is  admissible. 

Meats. — Meat  cannot  be  prohibited  entirely  for  months  at  a  time 
in  chronic  gout,  especially  for  a  middle-aged  man,  although  the 
young  may  thrive  better  without  it.  It  should  be  only  eaten  once  a 
day  in  any  case,  and  roasting  or  broiling  is  the  best  form  of  cooking 
it.  Twice-cooked  meats  should  not  be  eaten.  Beef,  lamb,  and  poul- 
try may  be  allowed  sparingly.  Generally  speaking,  white  meat  is 
better  than  brown. 

Veal,  pork,  fat  bacon  and  ham,  game,  and  dried,  smoked,  pickled, 
or  salted  meats  must  all  be  forbidden. 

Only  one  kind  of  meat  should  be  eaten  at  a  meal. 

Fats. — Fats  should  be  used  sparingly,  and  all  food  fried  or 
cooked  in  grease  must  be  forbidden.  Fat  meats  and  fat  fish  are  to 
be  avoided.  A  little  well-cooked  bacon  may  occasionally  be  eaten, 
and  butter  may  be  taken  only  in  moderation.  The  objection  to  the 
use  of  fats  and  oils  is  that,  unless  the  general  nutrition  is  very 
poor,  they  interfere  in  gouty  subjects  with  complete  oxidation  of 
proteid  elements. 

Farinaceous  Food. — Farinaceous  food  is  allowable,  and  in  the 
acute  stage  of  gout  it  should  constitute  the  main  diet.  Bread  (not 
fresh),  rice,  sago,  tapioca,  oatmeal,  cracked  wheat,  may  all  be  eaten. 
Pastry,  cake,  hot  rolls,  hominy,  griddle  cakes,  preserves,  and  confec- 
tionery of  all  kinds  are  forbidden. 

Sugar. — Sugar  has  not  proved  to  be  always  harmful  to  the  gouty, 
but  eaten  with  a  mixed  diet,  especially  with  fruits  or  drunk  with 
wines,  it  undergoes  fermentation  processes  which  are  at  once  dis- 
tinctly harmful.  It  is  generally  admitted  that  carbohydrates  eaten 
in  excess  with  other  food  are  more  injurious  than  fats  in  excess. 

Sweets,  jams,  and  jellies  of  all  kinds  are  forbidden.  When  sugar 
positively  disagrees,  a  little  glycerin  or,  better,  saccharin  or  diabetin 
(levulose)  may  be  substituted  for  it. 

Vegetables. — Of  vegetables,  although  a  great  variety  are  eaten, 
there  area  few  which  are  prohibited  on  account  of  the  fact  that  they 
contain  oxalic  acid,  which  is  closely  allied  to  uric  acid,  and  which 
produces  oxaluria.  These  are  sorrel,  radishes,  asparagus,  rhubarb, 
tomatoes,  and  spinach.  The  two  latter  are  allowed  by  some  au- 
thorities, however.  Beets  are  forbidden.  Vegetables,  such  as  cab- 
bage, onions,  old  peas,  beans,  and  corn,  if  they  occasion  flatulence, 
must  be  eschewed.  The  following  may  be  eaten  :  French  peas 
{petit  pots)  and  young  French  beans,  string  beans,  celery,  young 
tender  green  corn,  carrots  (very  moderately),  turnips,  parsnips,  po- 
tatoes (except  sweet  potatoes)  sparingly,  well-baked  and  mealy,  cu- 
cumbers, broccoli,  beet  tops,  cauliflower,  celery  plant,  eggplant, 
okra,  artichokes.     Salads,  provided  they  are  not  dressed  with  much 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  627 

oil,  are  allowable.  Vegetables  which  act  injuriously  on  account  of 
their  acids  are  made  still  more  harmful  by  being  cooked  with  sugar. 

Fruits. — Some  writers  allow  fruits  of  almost  every  kind,  both 
raw  and  cooked,  but  Sir  Dyce  Duckworth  and  many  authorities  de- 
clare that  fruits  in  general  are  harmful.  Sir  Andrew  Clarke  forbade 
their  use  in  toto.  If  they  produce  no  dyspepsia,  and  are  ripe  and 
fresh,  a  few  fruits  may  be  eaten,  such  as  stewed  pears,  or  apples 
stewed,  baked,  or  roasted ;  but  all  those  fruits  which  contain  large 
quantities  of  sugar,  such  as  grapes,  figs,  bananas,  prunes,  etc.,  must 
be  forbidden,  as  also  acid  fruits,  especially  strawberries.  No  fruits 
cooked  with  sugar  can  be  allowed.  Melons  are  forbidden.  Garrod 
expressly  forbids  all  stone-bearing  fruits,  and  says  that  subacid 
fruits  furnish  alkaline  salts  that  split  up  in  the  blood  and  reappear 
in  the  urine,  chiefly  as  potassium  carbonate,  and  stimulate  the  kid- 
neys.    Melons  are  usually  the  least  hurtful  of  fruits. 

Fothergill  wrote  :  "  The  potash  in  the  strawberry  renders  its  juice 
a  desirable  drink  for  the  gouty  and  for  strumous  children,"  but  there 
are  many  patients  who  cannot  eat  a  half  dozen  strawberries  without 
an  exacerbation  of  inflammation  in  a  gouty  joint. 

If  any  fruit  is  eaten  it  should  not  be  in  connection  with  other 
food  or  with  sugar.  Hence  all  candied  fruits  are  proscribed.  Nuts 
are  forbidden. 

Pickles,  vinegar,  spices,  strong  condiments,  salted  foods,  mush- 
rooms, and  truffles  must  all  be  forbidden. 

Eating  between  meals  and  at  irregular  intervals  is  injurious. 
Fresh  air  and  exercise  are  often  more  needed  than  extra  luncheons 
of  bouillon,  broths,  wines,  etc. 

Ralfe  gives  the  following  menu  for  breakfast  and  lunch  : 

Breakfast. — A  poached  ^g%,  bacon,  or  fresh  fish,  tea  (coffee  and 
cocoa  disagree)  without  milk  or  sugar. 

Light  Lunch. — A  clear  soup,  vermicelli  or  julienne,  sandwiches, 
cold  meat  with  salad. 

Dinner  is  to  be  eaten  not  too  late,  and  fully  three  hours  before 
retiring. 

Cantani's  treatment  of  gout  is  based  on  the  belief  that  all  sub- 
stances should  be  withheld  from  the  diet  which  retard  the  oxidation 
of  nitrogenous  food  or  lessen  alkalinity  of  the  blood.  He  there- 
fore prohibits  all  fatty,  farinaceous  and  saccharine  food,  including 
bread  and  potatoes,  sweet  fruits,  etc.,  but  allows  fish,  eggs,  broth, 
and  fresh  green  vegetables  to  be  eaten.  Especially  to  be  avoided 
are  milk,  cheese,  all  acid  foods,  pickles,  sweets,  pungent  condiments, 
bread,  rice,  potatoes,  all  farinaceous  foods,  and  coffee. 


628  I5IET   IN   DISEASE. 

BEVERAGES. 

Water. — It  has  been  already  stated  that  to  favour  the  washing 
of  waste  matter  from  the  system  it  is  desirable  to  drink  considerable 
quantities  of  fluid,  and  gouty  people  who  are  corpulent  usually  per- 
spire with  freedom ;  their  urine  therefore  becomes  concentrated, 
and  there  is  a  tendency  to  the  precipitation  of  uric  acid,  urates,  and 
oxalate  of  lime.  It  must  be  observed  that  the  presence  of  uric  acid 
in  the  urine  does  not  always  indicate  an  excess  of  that  acid,  and  it 
may  happen  that  the  urine  is  too  concentrated  or  otherwise  altered 
to  hold  it  in  solution,  and  hence  precipitation  results.  An  excess  of 
acid  phosphate  may  combine  with  the  sodium  and  potassium  which 
are  necessary  to  hold  the  uric  acid  in  solution  in  the  form  of  urates, 
and  it  is  deposited  in  insoluble  crystals.  Copious  draughts  of  hot 
water  at  bedtime  or  taken  on  rising  in  the  morning  are  often  pre- 
scribed, but  it  is  doubtful  whether  the  temperature  of  the  water  makes 
any  difference  in  the  desired  result  so  long  as  plenty  of  fluid  is  taken. 

Fluid  should  be  drunk  half  an  hour  before  meals,  when  the 
stomach  is  empty.  Besides  serving  to  cleanse  the  mucous  mem- 
brane of  the  alimentary  canal,  the  diuretic  action  of  water  will  be 
greater  when  absorbed  at  such  times. 

Sir  Dyce  Duckworth  holds  somewhat  different  views  in  regard  to 
water  drinking,  although  he  does  not  make  clear  his  reasons  for  so 
doing.  He  says  :  "  I  feel  sure  that  Sydenham  was  right  in  condemn- 
ing water  drinking  for  the  gouty.  *  Water  alone  is  bad  and  danger- 
ous, as  I  know  from  personal  experience.  When  taken  as  the  regu- 
lar drink  from  youth  upward  it  is  beneficial.'  "  He  prefers  to  allow 
a  moderate  quantity  of  wine — from  four  to  six  ounces  of  good  sound 
Bordeaux,  and  adds :  "  The  least  excess  is  harmful,  but  a  little  good 
wine  is  better  for  most  gouty  persons  than  water  drinking,  espe- 
cially after  middle  life."  This,  of  course,  was  written  for  English- 
men in  the  upper  classes,  whose  ordinary  consumption  of  wine  is 
greater  than  that  of  Americans  in  the  same  social  position.  Much 
depends  upon  one's  previous  habits  of  life,  and  in  this  country  ex- 
amples of  gout  may  not  rarely  be  found  among  patients  who  have 
never  been  in  the  habit  of  drinking  alcoholic  beverages  daily,  and 
such  persons  do  best  to  abstain  from  them  entirely. 

Tea,  Coffee,  etc. — Tea  and  coffee  are  admissible  among  bever- 
ages for  the  gouty,  and  it  will  be  found  that  they  are  less  likely  to 
cause  dyspepsia  if  taken  quite  weak  without  sugar.  A  quarter  of  a 
grain  of  saccharin  may  be  added  instead.  Senator  forbids  tea  and 
coffee,  and  prescribes  "  acorn  coffee."  Infusion  of  cocoa  nibs  is  less 
to  be  recommended  on  account  of  the  excessive  fat  which  it  holds. 
Esbach  states  that  he  has  found  oxalic  acid  in  it  also,  amounting 
sometimes  to  0.4  of  i  per  cent.     Chocolate  is  forbidden. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  629 

Patients  who  are  still  able  to  lead  active  outdoor  lives  are  able  to 
drink  more  alcohol  than  those  of  sedentary  habits,  without  aggravat- 
ing their  symptoms.  In  general  the  quantity  consumed  is  as  im- 
portant as  the  quality,  and  it  should  be  definitely  prescribed  and 
kept  within  bounds. 

Alcoholic  Drinks. — With  regard  to  the  use  of  alcoholic  bever- 
ages it  is  their  acid  and  saccharine  ingredients  rather  than  the 
alcohol  itself  which  disagree.  Strong  liquors,  diluted,  may  not  be 
injurious,  but  nothing  is  worse  than  rich  sweet  wines  and  malt 
liquors. 

It  is,  however,  true  that  alcohol  in  all  forms  lessens  the  elimina- 
tion of  tissue  waste,  and  decreases  the  volume  of  urea  and  uric  acid 
excreted.  According  to  Pfeiffer,  both  beer  and  wine  may  lessen  this 
volume  by  one  half;  on  the  following  day  it  is  increased,  and  subse- 
quently diminished  again.  The  longer  wines  have  been  fermented,  or 
the  more  complete  the  conversion  of  their  sugar  to  alcohol,  the  less 
hurtful  they  become  to  the  gouty. 

While  free  perspiration  exists  in  warm  weather,  and  free  diuresis 
as  well,  alcoholic  drinks  of  all  kinds  are  less  harmful.  Whatever 
form  of  alcohol  is  taken,  it  should  be  drunk  to  the  exclusion  of  all 
others,  for  mixtures  are  particularly  bad. 

Strong  beer,  ales,  porter,  stout,  all  malt  extracts,  and  sweet 
cider  must  be  absolutely  prohibited.  Sir  Henry  Thompson  and 
Germain  See  regard  cider  as  beneficial  as  a  solvent  of  uric  acid, 
but  by  others  it  is  looked  upon  as  injurious  on  account  of  the  malate 
of  potassium  which  it  contains,  and  which  it  is  claimed  favours  the 
formation  of  uric  acid  (Yeo).  Undoubtedly  the  alcoholic  drinks 
which  are  best  tolerated  by  the  gouty  are  good  French  Cognac  or 
old  Scotch  whisky  well  diluted  with  water,  ApoUinaris,  or  soda 
water.  Scotch  whisky  is  by  many  found  to  agree  better  than  any 
other  variety.  Weak  brandy  and  soda  may  be  substituted,  or  un- 
sweetened Plymouth  gin.  It  is  the  part  of  wisdom  to  abstain  entirely 
from  alcohol.  Very  many  persons  are  so  habituated  to  its  use 
that  they  are  unwilling  to  abandon  it,  and  a  compromise  must  be 
effected.  It  is  easier  for  them  to  give  up  certain  foods  than  drink. 
There  are  certain  wines  which  should  be  absolutely  prohibited, 
among  them  all  which  are  re-enforced  by,  or  which  contain  a  large 
proportion  of  saccharine  material.  Strong  port,  sherry,  champagne, 
Madeira,  Canary,  claret,  and  Burgundy  are  comprised  in  this  list. 

Port  wine  has  even  acquired  the  reputation  of  being  a  primary 
factor  in  producing  gout,  when  a  hereditary  diathesis  does  not  exist. 
It  is  an  incompletely  fermented  wine  to  which  alcohol  has  been 
added  for  preservation,  and  all  wines  of  this  class  are  the  worst 
forms  of  alcohol  for  the  gouty.  Garrod  says  that  exceptionally  a 
sound  sherry,  Amontillado  or  Manzanilla,  may  be  prescribed.    There 


630 


DIET   IN   DISEASE. 


are  patients,  too,  who  maintain  that  they  do  better  with  port  as  a 
daily  beverage  than  with  any  other  form  of  wine,  but  their  example 
would  be  a  very  unsafe  one  to  follow,  and  their  experience  is  due  to 
constitutional  idiosyncrasy. 

Duckworth  says:  "  Rhenish  wines  are  acid  and  harmful;  those  of 
the  Moselle  district  are,  however,  less  acid,  and  rather  better  borne. 
Australian,  Californian,  Hungarian,  Greek,  and  other  Mediterranean 
wines  are  too  strong,  and  after  a  time  generally  disagree." 

An  absolutely  dry  champagne  may  sometimes  be  permitted,  or 
very  dilute  and  weak  pure  claret.  The  stronger  clarets  containing 
more  tannin,  and  all  wines  with  much  free  acid,  are  injurious. 
Among  the  light  wines,  several  may  be  permitted  in  moderation, 
but  they  should  be  diluted  with  an  alkaline  water  in  order  to  com- 
pletely neutralise  any  acidity. 

Such  wines  should  be  either  long  bottled  or  drunk  fresh  from 
the  cask,  for  newly  bottled  wines  are  more  injurious. 

The  best  Bordeaux  and  lightest  Hungarian  wines,  light  hock  and 
a  still  Moselle,  such  as  Zeltinger,  may  be  drunk,  for  these  wines  are 
quite  thoroughly  fermented,  and  therefore  contain  no  sugar  or  free 
acid,  though  they  have  salts,  such  as  cream  of  tartar.  These  wines 
should  only  be  allowed  in  extreme  moderation,  not  over  half  a  pint 
in  a  day. 

Yeo  says:  "The  more  distinguished  the  diuretic  effect  of  the 
wine,  the  better,  as  a  rule,  will  it  agree  with  the  gouty." 

Ralfe's  practice  is  to  allow  no  wine  of  any  sort  with  dinner,  but 
afterwards  two  claret-glassfuls  of  some  light  wine  are  permitted ; 
and  he  says  that  a  tablespoonful  of  brandy  in  half  a  tumblerful  of 
water  before  meals  increases  the  secretion  of  gastric  juice.  If  the 
patient  is  weak,  or  suffers  from  insomnia,  he  gives  brandy  or  whisky 
at  bedtime  in  some  effervescing  water. 

He  states  that  in  his  experience  patients  who  have  been  long 
habituated  to  the  daily  use  of  port,  sherry,  or  ale,  often  become 
worse  when  a  sudden  change  is  made  to  claret  or  hock.  In  such 
cases  he  advises  changing  gradually  by  substituting  at  first  a  drier 
port  or  sherry. 

Usually  such  red  wines  as  St.  Julien  and  St.  Estephe  are  preferable 
to  the  higher  class,  such  as  Lafitte  or  La  Rose. 

Different  persons  show  peculiar  idiosnycrasies  in  regard  to  the 
gout-producing  influence  of  certain  wines.  Some  will  always  have 
gouty  inflammation  set  up  within  a  few  hours  in  a  particular  joint  by 
one  form  of  liquor  or  wine  and  not  by  others. 

Saline  W^aters. — Alkaline  and  saline  mineral  waters  have  a 
well-deserved  reputation  for  benefiting  gout.  Many  persons,  espe- 
cially obese  gouty  subjects,  are  helped  by  taking  one  or  two 
"  courses  "  of  treatment  a  year  for  two  or  three  successive  years  at 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


631 


Carlsbad,  in  Bohemia,  or  elsewhere.  Carlsbad  water  may  be  drunk 
at  home,  four  or  five  ounces  being  taken  on  rising  in  the  morning, 
or  an  equivalent  of  the  evaporated  salts — chiefly  sodium  sulphate. 

The  water  of  the  Kreuzbrunnen  at  Marienbad  has  essentially  the 
same  composition  with  that  of  Carlsbad,  and  contains  even  more 
sodium  sulphate.  Elderly  persons  may  be  injured  by  a  too  vigorous 
use  of  these  salines,  and  they  should  take  only  milder  alkaline  waters 
containing  less  sodium. 

The  German  Fachingen  water  has  proved  very  serviceable.  It 
contains  3  5  per  cent  of  bicarbonate  of  sodium  and  6  per  cent  of 
bicarbonate  of  lime. 

Vichy  is  good  for  strong  patients,  but  not  for  the  feeble  or 
anaemic.  It  also  contains  considerable  sodium  bicarbonate,  and  the 
Vals  water  has  more  sodium  carbonate  than  many  alkaline  waters. 
These  waters  favour  the  elimination  of  uric  acid  as  a  salt  rather 
than  in  the  free  state. 

Saratoga  alkaline  water  is  among  the  best  in  this  country  for 
gouty  patients.  It  contains  carbon  dioxide,  sodium  and  alkaline 
carbonates,  and  chlorides.  The  waters  of  the  St.  Clair  Spring  in 
Michigan,  and  St.  Catherine  Spring  in  Ontario,  are  good  alkaline 
salines  for  gout.  Many  lithia  waters  are  also  recommended,  but 
they  contain  little  lithium.  Apollinaris  and  Johannis  water  are  good. 
All  beverages  drunk  by  the  gouty  should  be  well  diluted,  and  mildly 
alkaline  mineral  waters  are  especially  valuable  for  this  purpose. 

Aids  to  Dietetic  Treatment. — The  individual  peculiarities  of 
digestion  should  be  carefully  studied  in  each  case  by  the  physician, 
and  the  patient  must  be  very  thoroughly  examined  in  regard  to 
the  minutiae  of  all  his  hygienic  and  dietetic  habits.  Meals  should 
be  taken  at  stipulated  hours — the  breakfast  on  rising,  dinner  not 
later  than  three  o'clock,  when  practicable,  and  late  suppers  should 
be  avoided.  Between  the  acute  attacks  it  is  absolutely  necessary  to 
maintain  digestion  in  a  normal  condition.  The  bowels  must  be  kept 
open,  and  the  condition  of  the  skin  should  be  actively  maintained 
by  cold  bathing  and  friction.  Exercise  should  be  taken  in  the  open 
air.  The  urine  should  be  frequently  examined,  with  especial  refer- 
ence to  the  hour  of  the  day  at  which  it  is  passed  and  the  relation 
which  its  composition  bears  to  the  food  eaten. 

Diabetes  Mellitus. 

Nature  of  the  Disease. — Diabetes  mellitus  is  a  disease  charac- 
terised by  the  passage  of  a  large  quantity  of  urine  containing  grape 
sugar  or  glucose  and  usually  of  high  specific  gravity — 1.035  or 
more — excessive  thirst,  and  sometimes  e;caggerated  or  perverted 
appetite  ;  progressive  emaciation  ;  muscular  weakness  and  languor. 
The  disease  runs  a  chronic  course,  and  the  majority  of  cases  ter- 


632 


DIET    IN   DISEASE. 


minate  fatally  in  from  two  to  four  years.  Death  may  result  from 
inanition  or  from  "diabetic  coma  "  or  other  causes.  Our  knowledge 
of  the  disease  has  been  very  largely  obtained  from  experimentation 
upon  the  lower  animals,  in  whom  diabetes  can  be  artifically  produced. 
The  treatment  is  almost  entirely  dietetic  and  hygienic,  for  as  yet  no 
medicinal  remedy  has  been  found  which  is  curative,  and  very  few 
have  been  discovered  which  are  even  palliative  in  any  number  of 
cases.  Diabetes  is  therefore  essentially  a  dietetic  disease,  for 
although  not  usually  caused  by  errors  in  diet  it  may  be  exception- 
ally so  produced,  and  most  cases  are  more  or  less  benefited  by 
dietetic  treatment,  while  some  may  undoubtedly  be  cured  by  it. 
The  terms  "  glycosuria  "  and  "  glucosuria  "  are  employed  by  some 
authors  to  denote  the  disease  diabetes  mellitus.  Their  proper  use, 
which  will  be  followed  in  this  article,  is  in  a  more  restricted  sense 
to  imply  merely  the  existence  of  saccharine  urine,  which  may  be  of 
temporary  occurrence  independent  of  the  other  symptoms  of  diabetes. 

Owing  to  the  somewhat  obscure  aetiology  of  diabetes  it  is  classed 
by  different  authors  among  various  diseases.  Thus  it  is  placed 
among  diseases  of  the  kidney  for  convenience  of  examination  of 
the  urine,  or  it  is  described  in  connection  with  diseases  of  the  liver, 
constitutional  diseases  or  disorders  of  the  digestive  system,  or  of 
alimentation.  In  the  mortality  statistics  of  the  United  States 
Census  it  is  classed  among  General  Diseases,  and  the  latter  class 
has  certainly  the  advantage  of  being  non-committal,  for  while  the 
liver  is  mainly  at  fault  in  diabetes  it  may  not  be  exclusively  so,  and 
the  disease  certainly  has  nothing  to  do  with  the  kidneys  beyond  the 
fact  that  they  have  extra  work  thrown  upon  them. 

Diabetes  has  long  been  known,  and  was  described  more  than  a 
century  ago ;  and  Rollo  inaugurated  the  dietetic  treatment  by 
withholding  vegetable  food.  In  1838  Gmelin  and  Tiedemann  estab- 
lished the  existence  of  the  relation  between  the  digestion  of  car- 
bohydrates and  the  formation  of  sugar.  In  1848  the  eminent 
physiologist  Claude  Bernard  began  elaborate  researches  which 
first  threw  definite  light  upon  the  relations  of  the  liver  to  the  con- 
sumption of  sugar  and  the  formation  of  glycogen,  and  since  that 
day  a  number  of  physiologists  and  clinicians  in  many  countries  have 
contributed  extensively  to  the  knowledge  of  the  disease.  Notwith- 
standing this  fact,  however,  the  true  cause  of  this  affection  is  still 
obscure,  and  aside  from  dietetic  treatment  but  little  advance  can  be 
claimed  in  regard  to  the  controlling  influence  of  medicine.  The 
method  of  production  and  elimination  of  the  sugar  and  the  in- 
fluence of  the  disease  upon  general  nutrition  is  understood,  but  its 
real  exciting  cause  and  the  fundamental  reason  for  the  interesting 
departure  from  the  normal  metabolism  of  starchy  foods  which  is  its 
basis  is  still  unknown. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


633 


Frequency. — Diabetes  is  not  a  very  rare  disease,  and  a  few 
cases  occur  from  time  to  time  in  the  experience  of  almost  every 
general  practitioner.  It  is  reputed  to  be  of  more  common  occur- 
rence to-day  than  it  was  forty  or  fifty  years  ago,  but  this  fact  is 
possibly  due  to  the  much  more  careful  and  frequent  urinary  analy- 
ses which  are  made  as  a  matter  of  routine  by  all  physicians,  that 
often  reveal  a  latent  diabetic  condition  which  might  otherwise  have 
been  overlooked.  In  regard  to  those  cases  which  are  of  neurotic 
origin,  the  general  increase  in  the  proportion  of  diseases  of  the 
nervous  system  which  has  been  observed  in  the  United  States  must 
be  taken  into  consideration.  In  the  United  States  Census  for  1880 
there  are  reported  1,443  deaths  from  diabetes  mellitus  (or  1.9  per 
cent  of  all  cases),  against  837  deaths  (or  1.7  per  cent)  in  1870.  Dia- 
betes may  occur  alone  or  in  association  with  a  variety  of  diseases, 
particularly  those  of  the  liver,  pancreas,  lungs,  and  nervous  system. 

Causation. — The  influence  of  heredity  can  be  traced  as  a 
factor  in  about  one  third  of  all  cases.  The  disease  may  occur  in 
any  climate  and  in  any  age  with  either  sex,  but  it  is  commonest 
with  males  in  the  proportion  of  three  to  one.  In  females  it  occurs 
oftenest  between  twenty  and  forty  years  ;  in  males,  between  thirty 
and  forty-five  years.  It  is  somewhat  more  common  among  the 
wealthy  than  the  poor  because  of  sedentary  habits  combined  with 
overindulgence  in  eating.  The  obese,  particularly  those  who  have 
much  omental  fat,  are  more  liable  to  diabetes  than  are  thin  persons 
who  are  more  active. 

Cantani  has  observed  the  unusual  prevalence  of  diabetes  in 
southern  Italy,  where  carbohydrates  are  so  extensively  used,  and  he 
believes  that  the  liver  is  exhausted  by  digesting  such  food,  while  at 
the  same  time  it  is  weakened  by  failure  to  receive  proteids.  This 
view  will  hardly  withstand  the  criticism  that  in  many  other  coun- 
tries the  natives  have  lived  for  generations  upon  carbohydrates 
without  developing  diabetes. 

Among  the  various  determining  causes  of  the  disease  have  been 
reported  blows  and  shocks  affecting  particularly  the  nervous  sys- 
tem, injuries  to  the  back  of  the  head  and  blows  over  the  liver,  as 
well  as  general  concussion,  such  as  that  produced  in  railway  acci- 
dents ;  exposure  to  cold,  wet,  and  fatigue ;  convalescence  from 
fevers;  emotional  strain,  worry,  mental  fatigue,  and  anxiety.  Tu- 
mours and  haemorrhage  at  the  base  of  the  brain  and  circumscribed 
lesions  of  the  floor  of  the  fourth  ventricle  have  been  known  to  oc- 
casion the  disease. 

Overindulgence  in  Food. — There  is  some  doubt  whether  any 
one  article  of  diet  can  determine  an  attack  of  diabetes,  although 
inordinate  eating  of  candy,  preserves,  raisins,  fruit,  confections,  etc., 
may  occasionally  cause  temporary  glycosuria. 


634 


DIET   IN   DISEASE. 


Bernard  claimed  that  taking  excess  of  starch  into  an  empty 
stomach  caused  transient  glycosuria  in  animals,  but  this  observation 
has  not  been  uniformly  confirmed  in  man. 

Fowler  wrote  some  time  ago  :  *'  I  have  been  in  the  habit  of  sup- 
plying my  classes  with  saccharine  urine  simply  by  taking  about  four 
ounces  of  dried  dates  or  about  a  tablespoonful  of  pulverised  glucose 
upon  a  fasting  stomach." 

According  to  Harley,  temporary  glycosuria  may  be  induced  by 
eating  asparagus. 

Rich  food  of  either  an  animal  or  vegetable  nature  keeps  the 
liver  constantly  overtaxed,  and  unrestrained  indulgence  in  sweets, 
new  wines,  and  sweet  fruits  is  said  to  excite  diabetes.  Sugar  may 
be  present  in  the  urine  in  the  proportion  of  from  five  to  ten  parts  per 
thousand,  but  so  long  as  its  occurrence  in  this  manner  is  of  brief 
duration,  and  so  long  as  it  can  be  immediately  traced  to  indiscre- 
tion in  the  abuse  of  saccharine  foods,  it  is  of  little  practical  signifi- 
cance. It  has  been  claimed  that  continued  eating  of  predrgested 
starchy  foods  containing  too  much  glucose  may  result  in  the  pro- 
duction of  diabetes. 

In  transient  glycosuria  the  ingestion  of  excess  of  cane  sugar 
does  not,  according  to  Worm-Miiller  and  others,  produce  glucose  in 
the  urine,  but  saccharose,  and  he  attributes  diabetes  to  overfermen- 
tation  on  the  part  of  the  liver. 

In  diabetes  lactose  reappears  in  the  urine  as  glucose,  but  under 
normal  conditions  if  eaten  in  excess  it  causes  a  transient  lactosuria. 

RELATION    TO   GOUT   AND   OTHER   DISEASES. 

The  frequent  association  of  gout  and  diabetes  has  long  been  ob- 
served, and  in  "gouty  glycosuria"  (Brunton)  comparison  is  made 
between  the  chronic  hypersemia  of  the  diabetic  liver  and  the  acute 
hypersemia  of  the  gouty  joints. 

Occasionally  persons  past  fifty  years  of  age  who  are  gouty  may 
present  the  symptom,  of  glycosuria  without  other  accompanying 
manifestations  of  diabetes,  such  as  emaciation  and  debility.  This 
symptom  may  persist  for  a  number  of  years  and  end  in  recovery,  or 
the  patient  may  die  of  some  intercurrent  disease  in  no  way  con- 
nected with  diabetes. 

In  a  long  series  of  cases  of  diabetes  reported  by  Ord,  gout  oc- 
curred in  over  one  third,  and  in  some  there  was  rheumatoid  arthritis. 
In  these  cases  not  only  does  the  urine  contain  sugar  in  excess,  but 
the  urea  and  uric  acid  are  largely  increased.  It  is  interesting  to 
remark  in  this  connection  that  similar  dietetic  treatment  benefits 
gouty,  obese,  and  diabetic  patients,  for  they  live  best  upon  a  nitrog- 
enous diet  with  alkalies.  The  occurrence  of  an  excess  of  uric  acid 
in  the  urine  (uricsemia)  is  often  a  forerunner  of  diabetes  (Coignard, 


DISEASES   ESPECIALLY   INFLUENCED   BY    DIET.  635 

Comillon).  Diabetes  is  also  often  associated  with  neuralgia,  phthisis, 
hepatic  engorgement,  and  congestion.  There  is  no  one  form  of  dis- 
ease of  the  liver  in  which  diabetes  is  uniformly  or  frequently  asso- 
ciated. In  about  one  third  of  the  cases  a  history  is  obtainable  of 
mental  strain  or  overwork,  and  in  about  one  third  there  is  a  history 
of  alcoholism. 

PHYSIOLOGICAL   EXPERIMENTS. 

In  order  to  understand  fully  the  dietetic  treatment  of  diabetes,  it 
will  be  necessary  to  discuss  somewhat  at  length  certain  physiological 
experiments  and  theoretical  causes  in  relation  to  aetiology.  These 
topics  will  be  found  to  throw  some  light  upon  the  relations  of  diet 
to  the  symptoms.  The  experiments  of  Claude  Bernard  above  al- 
luded to  were  made  to  determine  where  the  sugar  which  has  been 
ingested  by  an  animal  is  destroyed.  Claude  Bernard  was  the  first  to 
accurately  determine  the  amount  of  sugar  normally  present  in  the 
blood.  According  to  his  estimate,  when  this  quantity  does  not  ex- 
ceed three  parts  in  one  thousand,  the  limits  of  health  are  not  sur- 
passed, and  sugar  does  not  appear  in  the  urine,  as  it  promptly  does 
when  the  proportion  is  increased. 

He  fed  animals  heavily  upon  sugar,  killed  them,  and  examined 
the  blood  from  various  blood  vessels.  In  this  manner  he  ascertained 
that  a  good  deal  of  sugar  is  destroyed  by  the  passage  of  the  blood 
through  the  lungs,  but  he  also  found  it  to  be  carried  by  the  hepatic 
vein,  while  the  portal  vein  contained  a  trace  only.  He  demonstrated 
that  the  liver,  excised  from  the  body  and  washed  free  of  all  blood 
by  a  stream  of  water  injected  through  the  portal  vein,  would,  after 
standing  for  a  few  minutes,  still  yield  sugar.  He  thus  proved  that 
the  liver  is  capable  of  forming  sugar  by  some  process  which  is  con- 
tinued independently  of  its  blood  supply.  He  next  searched  for  the 
source  of  the  sugar  formed  by  the  liver,  and  discovered  the  sub- 
stance, to  which  he  gave  the  name  of  "  glycogen."  Glycogen,  or 
animal  starch,  is  a  normal  ingredient  of  the  liver  cells,  in  which  it  is 
stored  in  the  form  of  amorphous  granules  around  their  nuclei.  When 
treated  by  diastatic  ferments  or  boiled  with  dilute  mineral  acids,  it 
is  converted  into  a  grape  sugar  or  glucose,  Hensen,  of  Kiel,  dis- 
covered glycogen  independently  of  Bernard  and  at  nearly  the  same 
time.  This  substance,  which  is  isomeric  with  starch,  occurs  in  the 
skeletal  muscles  as  well. 

Bernard  also  found  that  the  quantity  of  sugar  which  he  could 
collect  from  the  hepatic  vein  at  any  time  did  not  increase  when  the 
animal  was  fed  upon  a  large  amount  of  sugar;  this  circumstance  led 
him  to  argue  that  the  liver  arrests  the  sug^r  ingested  on  its  way  to 
the  general  circulation,  and  thus  acts  as  a  regulator  of  the  amount 
of  sugar  contained  in  the  blood. 


636 


DIET   IN   DISEASE. 


Man  takes  his  food  at  comparatively  infrequent  intervals,  and  it 
is  important  that  the  energy  derived  from  the  ingestion  of  a  large 
meal  of  carbohydrates  should  not  be  immediately  expended,  but 
should  be  stored  in  some  form  which  will  enable  it  to  be  gradually 
used  in  the  intervals  between  digestion  of  meals,  and  in  any  emer- 
gency when  food  is  withheld  for  a  longer  time  than  usual.  The  liver 
affords  this  means  of  storing  a  considerable  amount  of  energy  by 
converting  the  sugar — brought  to  it  in  the  portal  system  which  has 
been  absorbed  from  the  intestinal  wall — into  glycogen,  a  temporary 
product  which  is  stored  and  held  back  in  the  liver  cells,  but  which 
can  be  readily  paid  out  in  small  quantities  from  time  to  time  into 
the  hepatic  blood  as  it  leaves  the  liver.  In  this  manner  an  excess 
of  sugar  ingested  or  an  excess  of  sugar  derived  from  the  digestion 
of  starchy  food  is  normally  kept  from  immediately  entering  the 
circulation,  and  its  use  is  economised  by  holding  it  back  until  it  is 
required  for  force  production.  The  ultimate  destination  of  the 
sugar  reformed  from  the  glycogen  of  the  liver  is  that  it  is  consumed 
either  in  the  capillaries  or  intercellular  spaces  or  in  the  muscular 
and  other  tissues  of  the  body  by  obscure  ultimate  processes  of  nutri- 
tion, which  result  in  its  splitting  up  into  carbonic  acid  and  water 
with  the  evolution  of  heat.  In  support  of  this  view  Claude  Bernard 
proved  that  there  was  less  sugar  in  systemic  venous  blood  than  in 
arterial  blood. 

Bernard  extracted  with  glycerin  a  diastatic  ferment  from  the 
liver  and  blood,  which  he  supposed  had  the  function  of  converting 
the  glycogen  into  glucose;  this  action  he  called  the  "glycogenic" 
function  of  the  liver.  The  sugar  absorbed  from  the  intestines  and 
arrested  in  the  liver  he  supposed  to  be  there  converted  into  glycogen 
by  the  glycogenic  ferment.  Glycogen  is  also  formed  from  peptones. 
Foster  says  that  glycogen  may  be  accumulated  in  the  liver  upon  a 
mixed  diet,  and  that  it  may  be  in  part  formed  by  dehydration  of 
sugar  derived  from  metabolism  of  proteid  food.  It  is  a  fact  that 
when  diabetes  is  once  established,  the  elimination  of  sugar  in  the 
urine  will  sometimes  continue  in  both  man  and  animals  kept  upon 
an  exclusive  nitrogenous  diet. 

The  foregoing  experiments,  verified  by  many  physiologists,  have 
given  rise  to  three  principal  theories  regarding  the  origin  of  glyco- 
suria, which  are  as  follows  : 

1.  It  is  due  to  impaired  glycogenic  function,  and  the  sugar  taken 
as  a  food  is  at  once  passed  into  the  general  circulation  unaltered. 

2.  It  is  due  to  increased  glycogenic  function  ;  there  is  an  over- 
production of  sugar  from  the  glycogen,  the  latter  being  derived  both 
from  sugar  and  peptones,  and  the  newly  formed  sugar  is  swept  into 
the  blood. 

3.  The   conditions   of  absorption   of  carbohydrates  and   of   the 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  637 

functional  activity  of  the  liver  may  remain  normal,  and  yet  the  final 
combustion  of  sugar  by  the  tissues  or  its  assimilation  by  them  may 
be  imperfect  and  lead  to  its  accumulation  in  the  blood  and  sub- 
sequent appearance  in  the  urine. 

The  three  conditions  mentioned  above  imply  either  diminished 
activity  of  the  liver,  increased  activity  of  the  liver,  or  a  normal  liver, 
the  fault  being  in  other  tissues  of  the  body.  , 

Either  one  will  give  rise  to  the  presence  of  an  abnormal  amount 
of  sugar  in  the  blood  (glycohaemia),  which  is  excreted  by  the  kid- 
neys (glycosuria).  To  aid  in  substantiating  these  theories,  it  should 
be  proved:  (a)  That  there  is  a  definite  relation  between  the  quantity 
of  sugar  that  leaves  the  liver  and  the  quantity  of  glycogen  remain- 
ing in  the  liver,  (d)  That  the  "glycogenic  ferment"  resembles 
diastase,  (c)  That  the  glucose  passing  through  the  hepatic  vein  is 
identical  with  the  sugar  which  can  be  formed  from  starch  by  fer- 
mentation, (d)  That  there  is  a  definite  relation  between  the  quan- 
tity of  hydrocarbons  (and  peptones)  entering  the  liver  and  the 
quantities  of  glycogen  and  glucose  subsequently  obtained.  The  ex- 
periments of  Bernard  have  been  in  the  main  confirmed  by  other 
physiologists,  but  there  is  exception  taken  to  some  of  them,  and  his 
theories  are  not  universally  accepted. 

It  is  probable  that  in  the  majority  of  cases  the  primary  difficulty 
is  to  be  found'in  altered  metabolism  in  the  liver. 

Pavy  strongly  favoured  the  view  that  diabetes  is  due  to  a  faulty 
action  of  the  liver  in  not  preventing  the  sugar  which  is  brought  to  it 
by  the  portal  vein  from  reaching  the  general  circulation. 

The  essential  difference  between  the  theories  of  Bernard  and 
Pavy  in  regard  to  the  glycogenic  function  of  the  liver  concerns 
merely  the  final  destination  of  the  glycogen.  Both  agree  as  to  the 
primary  conversion  of  sugar  from  the  portal  vein  into  glycogen,  but 
while  Bernard  believed  that  the  glycogen  is  reformed  into  glucose 
and  consumed  in  the  tissues,  Pavy  held  that  the  normal  use  of 
glycogen  is  in  the  formation  of  fat. 

Pavy  believed  that  a  small  amount  of  sugar  may  be  absorbed  by 
the  lacteals  during  the  digestion  of  sugars  or  starches  passing 
through  the  thoracic  duct  directly  into  the  venous  circulation  with- 
out entering  the  liver.  This  he  considered  a  normal  condition.  It, 
however,  requires  the  use  of  far  more  delicate  tests  than  those  com- 
monly employed  in  clinical  work  to  detect  the  minute  traces  of  sugar 
in  the  urine  which  Pavy  claimed  are  normally  present. 

Pavy  has  lately  propounded  another  ingenious  theory  to  account 
in  part  for  diabetes,  even  though  other  theories  be  not  wholly  aban- 
doned. It  is  that  the  intestinal  epithelium  of  the  villi  ordinarily  ex- 
erts a  sort  of  glandular  control  over  the  sugar  absorbed  from  the 
bowel,  and  converts  it  into  glycogen  and  fat  as  it  reaches  the  blood. 


638 


DIET    IN   DISEASE. 


Failure  to  perform  this  function  results  in  the  production  of  glyco- 
suria. This  failure,  Pavy  holds,  is  due  primarily  to  faulty  nerve 
action  affecting  the  calibre  of  the  arterioles  and  capillaries  with  hy- 
peroxidation,  which  favours  the  too  rapid  conversion  of  carbohy- 
drates into  glucose,  causing  glycosuria.  This  theory  has  been  some- 
what severely  criticised  by  Paten,  and  is  opposed  to  Seegen's  views, 
but  it  does  not  exclude  belief  in  the  storage  of  carbohydrates  as  gly- 
cogen in  the  liver — it  is  merely  accessory  to  it. 

If  the  liver  of  an  animal  be  rapidly  excised  and  cut  into  small 
fragments  to  prevent  further  fermentation,  it  will  be  found  on  anal- 
ysis to  contain  sugar  in  a  small  proportion  which  varies,  according 
to  different  observers,  between  0.2  and  0.6  of  i  per  cent  (Bernard  and 
Seegen) ;  hence  but  little  sugar  is  to  be  found  "in  the  liver  during 
life,  or  immediately  after  death,  and  it  has  been  suggested  by  Flint 
that  whatever  sugar  may  be  found  is  immediately  washed  out  by  the 
hepatic  blood  stream.  If  the  excised  liver  be  not  boiled,  but  be 
allowed  to  remain  at  the  body  temperature  for  some  minutes,  or  if 
the  portal  circulation  be  suddenly  cut  off  while  the  liver  remains  in 
the  body,  it  is  found  that  the  formation  of  sugar  continues  for  at 
least  an  hour,  owing  to  a  process  of  fermentation  which  produces  it 
from  glycogen.  From  these  and  other  experiments  it  is  believed 
that  the  glycogen  stored  in  the  liver  is  constantly  but  gradually  con- 
verted into  sugar,  which  is  carried  off  in  the  general  circulation  in 
such  small  quantities  that  it  is  often  difficult  to  detect  its  presence 
in  the  blood. 

Glycogen  is  found  in  the  muscles,  and  in  some  other  tissues  of 
the  body,  and  it  has  been  suggested  that  sugar  might  be  formed  in 
the  blood  vessels,  quite  independently  of  the  liver,  by  a  ferment  car- 
ried in  the  blood,  but  the  hepatogenous  origin  of  the  glucose  is  the 
view  generally  accepted  at  present. 

THE  NERVOUS  SYSTEM  AND  DIABETES. 
It  is  a  curious  fact  that  the  irritation  or  puncture  of  a  very  cir- 
cumscribed area  in  the  floor  of  the  fourth  ventricle  in  the  medulla  is 
followed  by  the  appearance  of  sugar  in  the  urine.  This  spot  is 
called  the  "  diabetic  centre,"  and  it  is  in  close,  relation  with  the  sym- 
pathetic and  vasomotor  ne.rves  that  control  the  capacity  of  the  he- 
patic blood  vessels.  In  animals  in  which  fatty  degeneration  of  the 
liver  cells  has  been  artificially  produced  by  metallic  poisoning,  punc- 
ture of  the  diabetic  centre  produces  glycosuria.  Glycosuria  is  also 
observed  in  men  after  the  inhalation  of  chloroform  and  in  animals 
after  the  inhalation  of  irritant  vapours  and  after  stimulation  of  the 
pneumogastric  nerve.  Schiff  produced  glycosuria  experimentally  by" 
the  removal  of  the  spleen  from  animals,  but  it  does  not  follow  this 
operation  in  man.     He  also  tied  off  successive  portions  of  the  liver 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET. 


639 


from  connection  with  the  circulation,  and  found  the  production  of 
sugar  proportionately  decreased.  The  frog  is  capable  of  surviving 
extirpation  of  the  liver  for  three  weeks,  and  at  the  end  of  this  time 
no  sugar  is  found  in  the  blood  (Schiff).  If  the  vagus  nerve  is  di- 
vided in  the  neck,  or  if  the  spinal  cord  be  divided  above  the  origin 
of  the  great  sympathetic  nerve,  diabetes  may  result.  Bernard  sug- 
gested that  glycosuria  might  be  cured  if  it  were  possible  to  galva- 
nise the  sympathetic  nerves.  The  foregoing  experiments  demon- 
strate that  glycosuria  may  be  caused  by  a  variety  of  nerve  lesions 
and  irritations.  It  is  also  frequently  associated  with  modifications 
in  the  activity  of  the  hepatic  circulation. 

THE  CIRCULATION  AND  DIABETES. 
The  occurrence  of  diabetes  in  connection  with  acute  inflamma- 
tions of  the  liver  and  passive  hepatic  congestion  secondary  to  ad- 
vanced cardiac  disease  favours  the  hypothesis  that  glycosuria  may  be 
developed  by  an  increase  in  the  amount  of  blood  flowing  through 
the  liver,  which  is  thereby  stimulated  to  an  active  conversion  of  its 
glycogen  into  sugar,  or  else  the  blood  passes  so  rapidly  through  the 
liver  that  the  sugar  absorbed  from  the  food  by  the  branches  of  the 
portal  vein  does  not  have  time  to  be  converted  into  glycogen,  but 
goes  through  the  liver  into  the  general  circulation  unaltered.  Thus, 
whether  the  glycogenic  function  be  increased  or  diminished  in  gly- 
cosuria, either  condition  would  demand  altered  activity  of  the  portal 
circulation. 

VARIOUS   THEORIES   OF   DIABETES.* 

Huppert,  Pettenkofer,  and  Voit  advocate  the  following  theory : 
Sugar,  like  urea,  is  a  normal  product  of  the  decomposition  of  albu- 
minous bodies.  In  health  the  sugar  is  oxidised;  in  diabetes  less 
oxygen  than  normal  is  absorbed,  owing  to  the  destruction  of  the 
red  blood-corpuscles  occasioned  by  malnutrition  ;  therefore  sugar 
accumulates  in  the  blood.  Sugar  is  formed  from  the  albuminous 
constituents  of  the  body  which  undergo  rapid  chemical  change. 
This  fact  they  regard  as  proved  by  the  increase  in  the  quantity  of 
urea  eliminated.  Von  Mehring  found  sugar  in  the  urine  of  a  dia- 
betic patient  after  a  twenty-six  hours'  fast. 

Porter  believes  that  the  renal  epithelial  cells,  which  he  claims  are 
frequently  enlarged  in  diabetic  patients,  take  an  active  part  in  the 
manufacture  of  glucose  because  the  blood  of  diabetic  patients  never 
contains  enough  sugar  at  any  one  time  to  account  for  all  which  is 
found  in  the  urine.  The  epithelial  cells  are  supposed  to  manufac- 
ture the  sugar  out  of  carbon  dioxide  and  water.  This  theory  lacks 
confirmation,  however,  and  it  should  be  observed  that  a  very  small 
amount  of  sugar,  which  furnishes  a  mere  trace  in  the  blood  at  any 
43 


640 


DIET    IN   DISEASE. 


one  time,  but  which  is  constantly  eliminated  from  the  large  quantity 
of  blood  continually  passing  through  the  kidneys,  may  amount  in 
the  course  of  twenty-four  hours  to  a  number  of  grammes.  In  view 
of  the  established  facts  in  regard  to  the  glycogenic  function  of  the 
liver,  it  seems  wholly  unnecessary  to  believe  that  the  renal  epithe- 
lium exercises  any  special  metabolic  power  in  diabetes;  moreover, 
the  kidneys  may  appear  quite  normal  in  severe  cases  of  diabetes. 

Brunton  reports  several  cases  due  to  the  presence  of  a  tape- 
worm. He  thinks  that  the  increased  appetite  caused  by  the  presence 
of  the  worm  may  have  been  instrumental  in  causing  the  glycosuria 
from  overeating,  but  it  is  possible  that  the  peripheral  irritation 
of  sympathetic  nerve  fibres  may  have  been  conveyed  to  the  diabetic 
centre  in  the  medulla,  and  thence  reflected  to  the  vasomotor  system 
of  the  liver. 

Some  recent  experiments  and  clinical  observations  justify  the 
belief  that  the  skeletal  muscles  play  a  more  important  role  in  the 
production  of  diabetes  than  has  heretofore  been  supposed. 

During  their  activity  they  normally  consume  glycogen  in  con- 
siderable quantity.  If  they  fail  to  perform  this  function  properly,  it 
accumulates  in  the  system. 

Kiilz  has  shown  that  muscular  activity  favours  the  consumption 
of  sugar  in  the  organism  of  the  diabetic,  and  that  much  less  sugar  is 
eliminated  while  such  patients  are  taking  vigorous  exercise. 

It  must  be  admitted  that  there  are  many  hepatic  diseases  and 
lesions  in  which  a  large  part  of  the  secreting  surface  of  the  organ  is 
destroyed,  and  in  which  glycosuria  may  never  be  present,  but  in 
these  conditions  it  is  possible  that  while  a  part  of  the  liver  is  totally 
destroyed  there  may  be  some  remaining  cells  which  are  still  endowed 
with  normal  functional  activity,  whereas  in  the  disease  under  discus- 
sion it  is  probable  that  none  of  the  parenchyma  of  the  liver  main- 
tains its  normal  control  over  metabolic  processes,  and  hence,  what- 
ever sugar  is  brought  to  the  organ  by  the  portal  vein  passes  into  the 
general  circulation  unaltered.  In  the  graver  forms  of  diabetes,  in 
addition  to  the  functional  disturbances  of  the  liver,  there  is  believed 
to  be  present  also  a  condition  of  malnutrition  in  which  sugar  either 
fails  to  be  consumed  or,  as  suggested  by  Yeo,  "  we  may  suppose  that 
in  these  cases  a  morbid  ferment  is  formed  in  the  system,  possibly  in 
connection  with  some  radical  fault  of  stomach  or  intestinal  digestion, 
and  that  this  determines  the  rapid  reconversion  of  glycogen  into 
sugar." 

Symptoms. — The  most  important  symptoms  of  a  typical  case  of 
diabetes  which  are  to  be  combated  by  diet  are  (a)  extreme  thirst, 
{b)  the  large  quantity  of  urine  voided  and  rapid  emaciation  and  loss 
of  strength. 

{a)   Thirst.     The  Mouth. — Thirst  becomes  extreme,  and   is   not 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  64I 

quenched  by  drinking,  although  patients  will  drink  almost  any  avail- 
able fluid — even  their  own  urine — in  their  endeavour  to  relieve  it. 

The  absorption  by  the  blood  vessels  of  fluid  from  the  tissues  is 
held  to  be  the  main  cause  of  this  extreme  thirst  (Vogel),  which  is 
most  intense  one  or  two  hours  after  meals,  when  sugar  formation  is 
most  active,  and  ten  or  fifteen  quarts  of  water  may  be  consumed 
daily  if  patients  are  not  restrained  from  drinking  freely. 

The  saliva  is  thick,  frothy,  and  acid,  and  often  contams  sugar. 

The  mouth  becomes  sticky  or  dry,  even  to  the  extent  of  interfer- 
ing with  articulation,  and  there  is  often  a  sweetish  taste,  which  may 
be  accounted  for  by  the  sugar  present  in  the  saliva  and  the  blood  of 
the  capillaries  which  circulate  among  the  taste  bulbs. 

The  tongue  is  at  first  moist  and  sticky  and  coated  with  promi- 
nent papillae;  later  it  may  become  dry,  dark  red,  and  fissured.  The 
appetite  is  at  first  excessive  ;  it  amounts  to  bulimia  in  some  cases ;  at 
other  times  it  is  capricious  or  intermittent,  and  subsequently  it  fails 
completely  when  the  digestion  becomes  impaired  through  the  symp- 
toms of  gastric  and  intestinal  catarrh. 

[b)  The  Urine. — The  average  quantity  of  urine  voided  is  between 
two  to  three  times  the  normal  amount — that  is,  from  3,000  to  4,500 
cubic  centimetres.  If  water  is  being  drained  from  the  tissues  the 
quantity  of  urine  voided  may  exceed  the  amount  of  fluid  ingested, 
but  obviously  tiiis  condition  cannot  last  very  long.  Exceptionally 
as  much  as  5,000  to  10,000  cnbic  centimetres  or  more  may  be  voided 
within  twenty-four  hours. 

Frequent  calls  to  micturate  at  night  greatly  interfere  with  the 
patient's  rest.  As  a  rule,  the  more  sugar  present  the  paler  is  the 
urine,  and  it  grows  turbid  soon  after  standing,  from  the  development 
of  yeast  fungus  [Torula  cerevisid),  derived  from  the  atmosphere. 
The  sediment,  if  present,  is  usually  light,  and  the  odour  may  resemble 
whey  or  hay.  The  urine  is  sweetish  ;  the  reaction  is  usually  quite 
acid,  but  may  be  neutral  or  alkaline,  and  the  acidity  is  usually 
proportionate  to  the  quantity  of  sugar ;  it  is  increased  by  develop- 
ment of  carbon  dioxide  and  acetic  acid,  products  of  fermentation. 
After  standing  it  does  not  become  alkaline  from  ammoniacal  fermen- 
tation, but  undergoes  saccharine  fermentation.  In  a  majority  of 
cases  the  specific  gravity  is  considerably  higher  than  the  normal, 
rising  to  between  1.035  ^"^  1-050  or  more.  Bouchardat  reports  a 
case  with  a  specific  gravity  of  1.074,  and  Pavy  one  with  a  specific 
gravity  as  low  as  i.oio,  which  is  certainly  exceptional.  The  specific 
gravity  rarely  falls  below  this  limit  if  any  sugar  is  present,  but  it  has 
been  found  as  low  as  1.002.  It  should  be  remembered  that  the 
quantity  of  urea  present  as  well  as  sugar  affects  the  specific  gravity. 

The  urea  is  proportionate  to  the  amount  of  proteid  food  elements 
ingested,  and  as  patients  are  usually  fed  upon  nitrogenous  food,  urea 


642 


DIET    IN   DISEASE. 


is  naturally  increased  beyond  the  normal  average.  Sometimes  two  or 
three  times  the  normal  quantity  is  excreted.  Urea,  however,  always 
exists  in  small  proportion  in  comparison  with  the  whole  quantity  of 
urine  voided.  There  are  some  instances  in  which  there  is  appar- 
ently an  increased  waste  of  the  albuminous  tissues  of  the  body, 
resulting  in  the  production  of  more  urea. 

The  quantity  of  sugar  present  varies  greatly;  an  average  may  be 
stated  as  from  thirty-two  to  thirty-five  parts  per  thousand  of  urine, 
but  the  total  may  even  exceed  five  hundred  grammes /(?r  diem. 

The  effect  of  a  heavy  meal  of  starchy  food  in  increasing  the 
sugar  is  promptly  shown  by  the  urine,  usually  within  two  hours,  and 
it  lasts  during  several  hours.  In  some  cases  very  little  sugar  is 
eliminated,  and  yet  the  symptoms  are  very  severe ;  in  others  a  great 
deal  is  voided  and  the  symptoms  are  not  at  all  severe,  but,  as  a 
rule  applying  to  a  majority  of  cases,  the  severity  increases  or  dimin- 
ishes with  the  quantity  of  sugar  passed.  After  grape  sugar  has  dis- 
appeared during  dietetic  treatment,  inosite  is  sometimes  found  in 
the  urine,  as  in  simple  polyuria.  Other  substances  found  occasionally 
in  connection  with  sugar  are  acetone,  alcohol,  or  peptones.  More  or 
less  albuminuria  is  observed. 

While  dietetic  treatment  is  in  progress  the  urine  should  be  period- 
ically tested  with  careful  relation  to  the  ingested  food,  and  speci- 
mens should  be  examined  which  are  passed  from  two  to  four  hours 
after  eating  various  articles  of  diet  in  order  to  observe  as  exactly 
as  possible  the  influence  of  such  diet  upon  the  elimination  of  glu- 
cose. 

The  Skin  and  Bowels. — Because  so  much  water  is  eliminated  in 
the  urine  there  is  scarcely  any  perspiration,  and  the  skin  becomes 
dry  and  wrinkled,  the  face  looks  drawn  and  pinched,  and  the  eyes 
are  hollow.  In  advanced  cases  a  sweetish,  sickening  odour  is  ex- 
haled from  the  skin  and  in  the  expired  air.  From  lack  of  intestinal 
secretion  the  bowels  are  usually  constipated,  although  diarrhoea  may 
alternate  with  constipation  in  the  later  stages  of  the  disease. 

Hunger. — At  first  the  food  eaten  does  not  supply  the  needs  of 
the  body  and  there  is  constant  craving  for  more. 

To  obtain  the  requisite  carbon  from  fats  a  labourer,  taking  his 
ordinary  allowance  of  proteids,  would  in  addition  have  to  eat  about 
three  hundred  and  fifty  grammes  of  fats,  which  would  be  manifestly 
impossible.  The  diabetic  is  practically  in  this  position  when  all 
carbohydrates  are  denied  him,  and  a  much  larger  bulk  of  food  is 
necessary  for  him  than  if  he  could  eat  food  containing  more  carbon 
but  less  proteid.  This  accounts  in  a  measure  for  the  extreme  hunger 
which  is  felt  by  many  diabetics  when  suddenly  deprived  of  their  ac- 
customed starchy  foods.  Some  writers  attribute  the  diuresis  to  the 
increased  consumption  of  albumins  which  is  necessitated. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  643 

Later  Symptoms. — In  the  later  stages  of  the  disease  dyspeptic 
symptoms  are  prominent  with  flatus,  sour  eructations,  and  a  disgust 
for  all  kinds  of  food.  The  teeth  decay,  the  gums  become  tender, 
and  mastication  is  difficult. 

The  alimentary  canal  is  frequently  the  seat  of  chronic  gastric 
catarrh,  with  thickening  of  the  mucous  lining  of  the  stomach  and 
small  intestine.  Diarrhoea  may  be  caused  by  the  excretion  of  sugar 
from  the  intestinal  mucous  surface.  Occasionally  nausea  and  vom- 
iting are  present,  and  the  ejecta  may  contain  acetone.  The  secre- 
tion of  bile  is  lessened.  Emaciation  sooner  or  later  becomes  extreme 
and  progresses,  although  the  appetite  remains  normal  or  may  be  still 
increased. 

The  loss  of  weight,  which  is  so  pronounced  a  feature  of  most 
advanced  cases  of  diabetes,  is  attributed  in  part  to  the  non-burning 
of  carbohydrates,  and  in  part  to  the  loss  of  their  albumin-protecting 
action  (Graham  Lusk),  In  health,  oxygen  is  used  to  consume  sugars, 
which  in  diabetes,  when  sugars  are  withheld,  burns  the  fat  of  the 
body  instead,  so  that  the  quantity  of  oxygen  inhaled  and  carbon 
dioxide  exhaled  may  remain  nearly  identical  in  the  two  conditions, 
while  emaciation  progresses.  In  addition  to  lack  of  nitrogen  of 
the  tissues  the  wasting  is  also  in  part  to  be  accounted  for  by  the 
drain  of  fluid  from  the  system  which  takes  place  when  once  over- 
action  of  the  ki^dneys  is  established.  Phthisis  is  often  present  and 
increases  the  rapidity  of  the  emaciation. 

Exceptionally,  early  in  the  disease  the  patient,  owing  to  the 
greater  appetite  and  the  large  amount  of  fluid  drunk,  may  increase 
somewhat  in  weight. 

Muscular  weakness  and  debility  rapidly  supervene  to  a  greater 
extent  than  is  to  be  accounted  for  by  the  usual  loss  of  flesh. 

In  general,  it  may  be  said  in  the  milder  forms  of  diabetes  that  the 
sugar  in  the  urine  is  derived  from  carbohydrate  foods,  while  in  the 
more  serious  forms  it  is  also  derived  from  the  nitrogenous  metab- 
olism. The  sugar  which  is  eaten  as  food  or  which  is  formed  by 
starch  in  the  alimentary  canal,  after  absorption  is  mainly  used  under 
normal  conditions  in  the  production  of  force,  but  in  diabetes  it  is 
eliminated  unaltered  from  the  body,  and  there  is  consequent  lack  of 
heat  production  and  muscular  power. 

Since  a  large  amount  of  heat-producing  material  passes  from  the 
body  without  complete  oxidation,  the  body  temperature  is  not  in- 
frequently subnormal,  and  it  may  so  remain  throughout  the  disease 
unless  there  be  some  inflammatory  complication.  The  axillary  tem- 
perature may  be  97°  or  even  95°  F.  The  occurrence  of  any  acute 
joint  or  visceral  inflammation  or  of  any  acute  fever  causes  a  reduc- 
tion in  the  quantity  of  sugar  eliminated  while  the  pyrexia  lasts.  The 
explanation  of  this  fact  is  by  some  observers  thought  to  be  due  to 


644 


DIET   IN   DISEASE. 


increased  combustion  of  sugar  in  the  body  during  the  pyrexial  stage, 
but  Bernard  attributed  it  to  an  interference  with  the  glycogenic 
function  of  the  liver.  The  pulse  becomes  rapid  and  feeble  and  the 
temperature  is  subnormal. 

When  great  feebleness  compels  the  patient  to  become  bedridden, 
bedsores  and  excoriations  from  frequent  passage  of  acid  and  sac- 
charine urine  add  to  his  discomfort. 

Diabetic  coma  is  the  precursor  of  sudden  death  in  a  certain  num- 
ber of  cases,  and  it  is  also  to  be  regarded  as  the  worst  possible  symp- 
tom which  may  arise.  Many  theories  have  been  offered  in  explana- 
tion of  this  symptom,  and  the  one  which  is  at  present  in  vogue  is 
that  it  is  produced  by  the  accumulation  of  acetone  in  the  system 
(acetonsemia).  Acetone  is  also  observed  in  other  forms  of  disease, 
and  although  it  may  be  present  in  the  expired  air,  urine,  ejecta,  or 
blood  of  diabetic  patients,  it  is  not  invariably  found.  When  present 
it  is  a  very  serious  symptom.  Gangrene,  asthenia,  or  intercurrent 
diseases  cause  a  number  of  deaths. 

There  are  other  symptoms  affecting  the  nervous  system,  the  eyes, 
etc.,  and  there  are  many  complications  which  may  arise  in  the  course 
of  the  disease,  but  a  consideration  of  them  would  lead  too  far  from 
the  object  of  the  present  discussion,  which  is  to  deal  with  those 
symptoms  which  bear  a  more  immediate  relation  to  the  metabolism 
of  the  food. 

Some  of  the  complicating  diseases  with  which  diabetes  may  be 
associated  make  it  impossible  to  adhere  to  a  rigid  regimen  without 
producing  more  harm  than  good.  Such,  for  example,  are  acute  gout 
and  chronic  nephritis,  in  both  of  which  a  meat  diet  is  injurious,  and 
if  carbohydrates  are  also  cut  off  the  patient  has  little  or  nothing 
left  to  eat.  In  these  cases  the  diet  must  be  determined  by  the  graver 
complication  (see  page  470). 

Course. — The  course  of  diabetes  is  so  protracted  that  there  is 
abundant  opportunity  and  usually  necessity  for  trying  dietetic  ex- 
periments, for  it  will  be  found  impossible  to  establish  rules  for  die- 
tetic treatment  to  which  exceptions  may  not  arise  from  time  to  time 
in  the  course  of  any  individual  case.  The  disease  is  sometimes  well 
established  long  before  its  symptoms  become. sufficiently  urgent  to 
attract  the  attention  of  the  patient.  Persons  who  believe  themselves 
to  be  in  perfect  health  and  who  apply  for  life-insurance  examination 
may  be  informed  for  the  first  time  of  the  presence  of  glycosuria, 
and  many  cases  are  now  discovered  through  incidental  examination 
of  the  urine  in  connection  with  some  other  disease,  which  would  have 
been  overlooked  a  few  decades  ago,  when  clinical  urinalysis  was  very 
imperfect. 

If  treatment  is  begun  before  the  symptoms  are  well  advanced 
the  lives  of  many  patients  may  be  prolonged — in  some  cases  for  more 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET,  645 

than  ten  or  twelve  years — whereas,  of  seven  hundred  cases  reported 
by  Prout  which  occurred  over  thirty  years  ago,  only  two  lived  be- 
yond ten  years.  Frerichs  reported  one  case  which  extended 
through  twenty  years  and  several  more  in  which  the  disease  lasted 
between  ten  and  eighteen  years.  Occasionally  diabetes  is  extremely 
acute,  and  may  prove  fatal  within  three  weeks,  but  in  such  instances 
it  is  probable  that  glycosuria  has  been  present  for  a  long  time  with- 
out discovery. 

Prognosis. — Between  50  and  60  per  cent  of  all  cases  are  fatal  in 
less  than  three  years;  undoubtedly  a  few  which  are  recognised- 
sufficiently  early  may  be  completely  cured,  but  glycosuria,  like  al- 
buminuria, indicates  a  weakness  of  the  system  in  a  special  direc- 
tion, and,  the  disease  having  once  occurred,  the  patient  should  be 
under  reasonable  supervision  for  many  years.  It  has  been  aptly 
said  that  "  the  only  chance  that  a  diabetic  has  of  being  cured  is  to 
believe  that  he  never  is  cured" — that  is,  to  be  constantly  on  the  alert 
to  avoid  all  indiscretions  in  hygienic  and  dietary  matters.  There 
seems  to  be  a  relation  between  the  general  bodily  nutrition  and  the 
chance  of  recovery  or  improvement.  Usually  stout,  middle-aged 
men  yield  best  to  treatment;  thin  persons  withstand  the  disease  less 
well,  and  rapid  emaciation  is  always  more  to  be  dreaded  than  the 
presence  of  sugar.  The  prognosis  is  more  favourable  in  those  cases 
which  are  readily  amenable  to  the  influence  of  a  strict  dietetic  regi- 
men. The  prognosis  is  more  favourable  if  the  sugar  does  not 
speedily  return  if  the  dietetic  treatment  be  interrupted,  and  also 
if  the  amount  of  urea  excreted  is  large  and  the  quantity  of  uric  acid 
small.  Cases  which  occur  in  connection  with  gout  are  relatively 
light.  In  emaciated  cases  the  malnutrition  is  so  great  that  the  pa- 
tients easily  acquire  other  diseases,  especially  pulmonary  tubercu- 
losis, and  many  die  from  complications  rather  than  from  the  imme- 
diate effect  of  the  disease  itself. 

Diagnosis. — Temporary  glycosuria  may  be  caused  by  a  variety 
of  conditions,  such  as  excessive  indulgence  in  sweets,  poisoning  from 
amyl  nitrite,  mercury,  chloroform,  alcohol,  etc.  It  has  been  ob- 
served during  pregnancy  and  after  anthrax,  diphtheria,  scarlatina, 
typhoid  fever,  etc.  In  the  transient  form  of  glycosuria  the  urine 
contains  much  less  sugar  than  in  diabetes  mellitus,  and  all  the  severe 
symptoms  of  excessive  thirst,  emaciation,  and  extensive  tissue  waste, 
leading  to  local  disease  and  usually  death,  are  wanting. 

In  polyuria  or  diabetes  insipidus  there  is  no  sugar  in  the  urine, 
and  the  specific  gravity  is  very  low — 1.002  to  1.005. 

Primary  peptonuric  diabetes  is  described  by  Quinquand  as  a  dis- 
ease presenting  the  clinical  features  of  niellituria — thirst,  marked 
cachexia,  polyuria,  etc. — but  instead  of  sugar,  the  urine  contains 
peptones;  it  polarises  to  the  left,  and  is  of  low  specific  gravity. 


646 


DIET    IN    DISEASE. 


Temporary  lactosuria  sometimes  occurs  as  an  accompaniment  of 
the  puerperal  state,  and  is  not  of  special  dietetic  significance. 

Treatment. — The  treatment  of  diabetes  to-day  is  much  more 
successful  than  it  was  thirty  or  forty  years  ago,  when  every  case  was 
regarded  as  necessarily  fatal.  The  treatment  should  be  (i)  prophy- 
lactic, (2)  dietetic,  (3)  hygienic,  and  (4)  medicinal. 

Prophylaxis. — Until  more  is  known  of  the  aetiology  of  dia- 
betes definite  prophylactic  rules  cannot  be  established ;  but  in  gen- 
eral, where  there  is  distinct  heredity  to  be  feared,  or  when  the  lithic- 
acid  diathesis  exists,  all  excitement  of  the  nervous  system,  mental 
or  physical,  as  well  as  indulgence  in  alcohol  and  sweets,  should  be 
strenuously  avoided. 

Dietetic  Treatment. — General  Observations. — When  pre- 
scribing any  dietetic  regimen  for  diabetic  patients,  the  general  con- 
dition of  bodily  nutrition  must  be  carefully  considered.  Obese, 
naturally  robust,  and  sometimes  gouty  patients  will  be  benefited  by 
very  strictly  limited  and  carefully  regulated  diet,  but  emaciated  and 
feeble  patients  cannot  always  endure  the  severity  of  a  strict  diabetic 
diet  without  too  great  loss  of  vitality,  and  it  becomes  necessary  to 
maintain  their  strength  even  at  the  cost  of  sometimes  increasing  the 
amount  of  sugar  in  the  urine.  Obese  persons  make  their  fat  largely 
out  of  carbohydrates,  and  hence  a  nitrogenous  diet  is  particularly 
well  suited  to  their  condition,  whereas  emaciated,  weak  patients  gain 
no  flesh  upon  an  exclusive  nitrogenous  diet,  and  it  may  barely  sup- 
port life  for  them. 

Some  persons  with  diabetes  have  been  said  to  excrete  more  sugar 
on  a  diet  of  animal  food  than  on  the  hydrocarbons,  but  it  will  gener- 
ally be  found  that  such  patients  have  eaten  some  farinaceous  food, 
bread,  etc.,  with  their  meat,  and  the  combination  seems  particularly 
favourable  to  the  maintenance  of  a  secretion  of  saccharine  urine 
once  established. 

Regulation  of  the  diet  should  be  faithfully  tried  before  any  medi- 
cation is  resorted  to,  for  the  latter  frequently  becomes  superfluous, 
but  a  placebo  may  be  given  if  necessary.  During  the  siege  of  Paris 
in  187 1  it  was  observed  that  a  number  of  diabetics  improved  consid- 
erably owing  to  the  enforced  restriction  in  their  diet  (Bouchardat). 

Cantani  advises  a  preliminary  fast  of  twenty-four  hours  before 
commencing  dietetic  treatment,  but  the  value  of  this  expedient  is 
questionable. 

Phenomenal  improvement  follows  in  many  cases  upon  a  diet 
which  excludes  starches  and  sugars  almost  completely,  but  this  is  a 
difficult  regimen  to  enforce,  for  the  craving  for  carbohydrates  espe- 
cially for  bread,  becomes  so  fierce  that  patients  whose  veracity  is 
otherwise  unimpeachable  will  resort  to  lying  or  any  form  of  decep- 
tion to  obtain  this  coveted  food. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  64/ 

It  is  a  matter  of  common  experience  that  the  most  difificult  of 
all  food  for  a  man  to  be  deprived  of,  when  once  accustomed  to  it,  is 
bread.  This  has  always  been  found  to  be  the  case  in  arctic  expedi- 
tions in  which  men  have  been  reduced  to  a  starvation  dietary,  and  it 
is  usually  observed  in  any  form  of  largely  restricted  diet,  although 
patients  who  are  living  upon  an  exclusive  diet  of  milk  appear  to 
have  somewhat  less  craving  for  it  than  diabetics,  who  are  allowed  a 
greater  variety  of  food,  especially  meat.  This  is  due  in  part  to  life- 
long association  of  certain  kinds  of  food  with  one  another  at  meals 
and  the  habit  of  eating  this  one  article  of  food  with  more  constancy 
than  any  other,  but  it  is  also  undoubtedly  referable  to  a  positive 
craving  of  the  system,  which  is  particularly  marked  in  diabetes,  for 
a  kind  of  food  which  the  tissues  need  but  cannot  assimilate.  For 
this  reason  it  is  generally  advisable  to  allow  patients  from  two  to 
four  or  even  six  ounces  of  bread  a  day  in  divided  portions;  other- 
wise the  craving  for  it  does  them  positive  harm,  and  a  loathing  for 
all  food  results,  or  they  break  all  restraints  and  injure  themselves 
more  by  overeating. 

It  should  be  remembered  that  diabetic  patients  are  very  sus- 
ceptible to  the  influence  of  the  nervous  system,  and  that  worry  and 
anxiety  about  themselves,  with  too  close  an  observation  of  their 
own  diet,  will  often  react  unfavourably.  Moreover,  it  is  undoubt- 
edly much  harder  for  these  patients  to  restrain  themselves  from  eat- 
ing varieties  of  Food  which  are  not  wholesome  for  them  if  they  sit 
at  a  general  table  where  others  are  indulging  in  various  luxuries  of 
the  season.  It  is  sometimes  possible  for  them,  as  has  been  proved 
by  Cantani,  to  maintain  good  health  for  many  years  upon  a  strictly 
nitrogenous  diet,  but  in  attempting  to  enforce  any  rigid  dietetic  sys- 
tem one  is  compelled  to  have  some  regard  for  the  environment  and 
general  habits  of  life  of  the  patient,  and  it  is  easy  to  make  the  indi- 
vidual so  miserable  by  too  harsh  rules  as  to  defeat  the  very  object  in 
view,  and  the  adoption  of  a  too  restricted  system  of  diet  may  result 
in  disastrous  failure.  For  these  reasons  it  is  now  customary  to  allow 
patients  a  more  liberal  dietary  in  diabetes  than  was  at  first  permitted 
after  the  discovery  of  the  real  nature  of  the  disease  and  the  influence 
of  carbohydrates  upon  it,  but  they  should  always  be  given  carefully 
written  directions  as  to  what  articles  they  may  eat  and  what  must 
be  avoided. 

While  it  is  necessary  to  secure  the  intelligent  co-operation  of  the 
patient  in  regard  to  carrying  out  his  treatment,  it  is  highly  undesir- 
able that  he  should  devote  too  much  time  and  attention  to  it,  and, 
when  possible,  it  is  better  to  have  some  one  else  select  and  provide 
food  for  him  in  order  that  his  mind  may  not  be  constantly  occupied 
with  questions  of  dietetics  which  tend  to  restrict  the  appetite,  and, 
sometimes  to  materially  interfere  with  the  beneficial  effects  of  the 


648 


DIET   IN   DISEASE. 


diet.  There  is  the  more  need  for  supervision  of  the  diet  by  a  second 
person,  because  the  craving  of  diabetic  patients  often  attains  an 
ascendency  over  their  will  power  and  habits  of  truthfulness;  in  fact, 
a  lack  of  mental  force  and  even  imbecility  are  quite  characteristic  of 
the  advanced  disease. 

Deception  should  be  suspected  in  those  cases  in  which  there  is 
more  urine  passed  than  is  to  be  accounted  for  by  the  quantity  of 
fluid  allowed  in  the  diet,  and  in  those  cases  which  apparently  ought 
to  improve  upon  dietetic  treatment,  but  in  which  after  repeated 
trials  no  headway  is  made  in  regard  to  controlling  the  amount  of 
sugar  in  the  urine.  I  have  known  hospital  patients  to  steal  bread 
and  potatoes  and  consume  them  surreptitiously  in  spite  of  repeated 
warnings,  and  also  to  acquire  such  a  craving  for  fluid  as  induced 
them  to  drink  their  own  urine. 

With  regard  to  the  suddenness  with  which  the  diabetic  regi- 
men should  be  adopted  by  the  patient,  it  is  found  to  be  the  rule 
that  it  is  easier  for  most  patients  to  begin  with  the  fully  restricted 
diet  at  once  than  to  gradually  eliminate  one  article  after  another 
from  the  menu.  The  urine  should  always  be  thoroughly  examined, 
both  qualitatively  and  quantitatively,  for  sugar,  urea,  and  albumin, 
before  the  restricted  diet  is  commenced,  and  periodic  examinations 
must  be  made  during  the  course  of  the  treatment  in  order  to  deter- 
mine the  effect  upon  the  disease  of  withholding  difl^erent  articles  of 
food  and  drink. 

At  first  it  is  well  to  make  such  examinations  daily,  and  subse- 
quently, if  the  patient  is  doing  well,  once  or  twice  a  week  is  suf- 
ficient. 

The  effect  of  no  dietetic  system  is  immediate,  and  at  least  two 
days  may  be  required  for  the  patient  to  come  fully  under  the  influence 
of  treatment,  because  the  materials  already  present  in  the  body  when 
the  new  diet  is  commenced  may  serve  as  a  source  of  sugar  for  some 
little  time  afterwards. 

The  general  principles  for  the  dietetic  treatment  of  diabetic  pa- 
tients are,  first,  to  exclude  from  the  diet,  when  possible,  all  those 
articles  which  are  most  likely  to  result  in  the  formation  of  sugar ; 
secondly,  to  devise  means  for  relief  of  the  craving  for  starchy  and 
saccharine  foods  which  patients  kept  on  a  nitrogenous  diet  are  cer- 
tain to  experience  before  long,  and  to  see  that  while  reducing  the 
amount  of  sugar  in  the  food,  the  patient  is  not  suffering  to  a  danger- 
ous extent  from  lack  of  nutrition.  It  is  difficult  to  formulate  rules 
of  diet  which  can  be  adhered  to  in  all  cases.  There  are  many  pa- 
tients confined  to  an  exclusive  nitrogenous  diet  who  lose  flesh  and 
strength  so  rapidly  that  although  the  advantage  of  reducing  the 
glycosuria  is  attained,  a  new  danger  arises  from  anaemia  and  emacia- 
tion. 


DISEASES   ESPECIALLY    INFLUENCED    BY    DIET.  649 

For  convenience  of  description  of  dietetic  treatment  cases  of 
diabetes  may  be  subdivided  into  three  classes :  (o)  Those  patients 
who  pass  a  considerable  quantity  of  urine  containing  a  large  percent- 
age of  sugar,  but  in  whom  the  general  health  is  still  good,  (d)  Cases 
in  which,  in  addition  to  the  passage  of  considerable  sugar  in  the 
urine,  there  is  more  or  less  dyspepsia,  emaciation,  and  debility,  (c) 
Cases  in  which  the  constitutional  symptoms  become  rapidly  severe 
after  the  first  appearance  of  sugar  in  the  urine. 

(a)  In  the  first  class  of  cases  the  dietetic  treatment  is  productive 
of  the  greatest  benefit,  and  not  rarely  the  patients  begin  to  gain 
flesh  and  strength ;  they  sleep  better ;  the  daily  quantity  of  urine 
falls  perhaps  from  three  hundred  ounces  to  seventy,  and  it  approaches 
the  normal  composition  ;  the  excessive  appetite  and  thirst  diminish  ; 
the  digestion  improves,  and  in  one  to  three  weeks  the  sugar  may  en- 
tirely disappear.  Such  patients  are  not  to  be  regarded  as  cured, 
however,  as  soon  as  the  sugar  disappears — not,  in  fact,  until  they  can 
eat  starches  in  ordinary  quantity  without  exciting  the  appearance  of 
glycosuria.  According  to  the  statement  of  Dujardin-Beaumetz,  pa- 
tients of  this  class  may  be  cured  who  have  been  eliminating  as  much 
as  three  thousand  grains  of  sugar  />er  diem.  Whenever  sugar,  or 
amylaceous  food  absorbed  as  sugar,  passes  through  the  circulation 
unaltered,  it  is  of  no  value  to  the  system,  and,  as  Bauer  says,  it  serves 
merely  as  "useless  ballast." 

{b)  The  secoftd  class  of  cases  is  also  amenable  to  dietetic  treat- 
ment, but  the  benefit  is  not  so  immediate  and  usually  not  so  great 
as  in  the  first  group,  and  it  may  be  impossible  to  cause  the  total  dis- 
appearance of  the  sugar,  although  it  may  be  reduced  to  two  hundred 
or  three  hundred  grains  a  day.  When  the  amount  of  urine  is  less- 
ened by  the  changes  of  menu,  the  specific  gravity  remains  high,  and 
sugar  is  abundant,  the  prognosis  is  very  grave.  The  patient  cannot 
tolerate  the  diet,  and  drugs  must  be  resorted  to. 

[c).  In  the  third  and  most  severe  class  of  cases  dietetic  treat- 
ment is  sometimes  of  avail,  and  it  should  be  always  undertaken,  for 
it  may  prevent  the  patient  from  becoming  worse,  although  it  is  un- 
able to  accomplish  a  cure. 

But  usually  the  treatment  of  these  cases  is  unsatisfactory,  be- 
cause the  patients,  who  are  often  young  subjects,  continue  to  form 
sugar  from  nitrogenous  food  after  starches  and  sugars  have  been 
proscribed,  and  it  is  practically  impossible  to  devise  any  special  com- 
bination of  food,  or  to  find  any  single  food  upon  which  they  can  sup- 
port life  and  from  which  they  are  not  able  to  produce  sugar.  Their 
nutrition  is  extremely  poor,  and  they  go  rapidly  from  bad  to  worse. 
Not  seldom  they  are  thin,  neurotic  subjects  when  the  disease  first 
attacks  them,  and  therefore  have  very  little  capital  to  draw  upon. 
In  extreme  cases  a  careful  comparison  between  the  amount  of  food 


650 


DIET   IN   DISEASE. 


ingested  and  sugar  eliminated  has  furnished  evidence  that  they  are 
even  capable  of  manufacturing  sugar  or  glycogen  out  of  the  muscu- 
lar tissues  of  their  own  bodies. 

A  clinical  comparison  of  the  different  varieties  of  diabetes  above 
described,  with  the  theories  which  have  been  discussed  in  regard  to 
the  possible  method  of  the  production  of  the  disease,  emphasises  the 
conclusion  that  cases  of  diabetes  may  not  all  have  exactly  the 
same  aetiology. 

By  different  writers  all  gradations  of  diet  have  been  recom- 
mended, so  long  as  the  carbohydrates  are  restricted,  from  the  ab- 
solute meat  diet  of  Cantani  to  the  skim-milk  diet  of  Donkin  and  the 
more  liberal  menu  of  the  majority  of  authorities. 

Some  patients  who  have  a  very  good  appetite  when  allowed  a 
mixed  diet  lose  it  altogether  when  put  upon  an  exclusive  nitroge- 
nous regimen.  There  are  those  who  can  live  contentedly  on  an  ex- 
clusive diet  of  proteid  food  and  fats  for  a  certain  length  of  time — 
say  ten  days  or  a  fortnight — if  the  principle  of  the  treatment  be  ex- 
plained to  them  and  they  are  anxious  of  being  cured,  but  sooner  or 
later  they  almost  always  find  it  intolerable  to  wholly  abstain  from 
starchy  and  saccharine  foods,  and  the  craving  for  such  articles  in 
some  cases  is  so  great  that  the  patient's  moral  nature  suffers  se- 
verely. Many  prefer  to  live  less  long,  but  in  more  comfort  than 
such  restriction  implies. 

This  is  probably  attributable  more  to  long-continued  habit  or 
heredity  than  actual  inability  to  support  life  on  a  purely  nitrogenous 
diet,  for,  as  stated  elsewhere  (page  292),  the  Eskimos  thrive  upon 
a  diet  absolutely  free  from  starches  and  sugars  of  every  kind.  It  is 
believed  by  Ebstein  and  others  that  an  exclusive  meat  diet  may  be 
injurious  on  account  of  a  tendency  to  produce  acetongemia,  and  it 
may  favour  the  increase  of  uric-acid  deposits  in  those  having  the  uric- 
acid  diathesis.  To  obtain  enough  carbon  from  such  a  diet  for  the 
needs  of  the  system,  a  very  large  quantity  of  proteid  food  must  be 
consumed. 

When  chronic  nephritis  complicates  diabetes  the  difficulty  of  diet- 
ing is  much  enhanced,  for  meat  is  injurious  for  the  nephritis,  and 
starches  are  prohibited  in  diabetes.  This  condition  has  been  aptly 
described  as  the  "  Scylla  and  Charybdis  of  the  diabetic."  As  a  com- 
promise such  patients  must  usually  be  put  upon  a  milk  diet. 

Dujardin-Beaumetz  states  that  when  the  quantity  of  sugar  elimi- 
nate^ falls  to  ten  grammes  a  day,  less  rigorous  withholding  of  starches 
is  needed. 

In  prolonged  cases  it  will  usually  be  found  that  patients  do  better 
with  occasional  variation  in  their  diet,  even  if  it  involves  giving  a 
little  amylaceous  food  for  a  few  days. 

Mild  cases  of  diabetes  seldom  occur  in  children,  hence  the  diet 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  65 1 

for  them  must  be  even  more  closely  confined  to  proteids  than  for 
adults. 

A  fair  sample  diabetic  menu  is-  the  following  (Pepper,  Medical 
Record,  New  York,  1884,  vol.  xxv,  p.  11)  : 

Breakfast  or  Supper. — Tea,  lemonade  (no  sugar),  soft-boiled  eggs, 
broiled  chop,  beefsteak  or  any  fish,  raw  tomatoes  or  onions  with 
vinegar,  a  very  little  toasted  bread  or  biscuit,  butter,  cream. 

Dinner. — Meat  (fat),  string  beans,  cauliflower,  lettuce,  game  (ex- 
cept their  livers),  cheese,  nuts  (except  peanuts  and  chestnuts). 

Many  elaborate  diet  tables  have  been  prepared,  and  for  those 
whose  means  permit  of  indulgence  in  delicacies  considerable  variety 
may  be  secured  without  the  use  of  carbohydrates  ;  but  for  the  poor 
in  hospitals  and  at  home  it  is  a  difiicult  problem  to  furnish  inexpen- 
sive variety  without  occasional  recourse  to  starchy  foods. 

Foods  allowed  in  Diabetes. 

Soups  and  broths  made  of  meat  of  any  kind  without  vegetables,  ox- 
tail and  turtle  soup,  gumbo,  curry. 

£ggs  in  any  form. 

Crustaceans,  crabs,  lobsters,  shrimp. 

Fresh  fish  of  all  kinds  and  fish  roe.  Caviare,  anchovies.  Salt 
fish,  cod,  mackerel,  and  herring  may  be  allowed,  unless  they  increase 
thirst  too  much. 

Fresh  meat,  fowl  and  game  of  all  kinds.  Ham,  bacon,  smoked 
beef,  tongue,  sweetbreads,-  kidneys. 

Fats. — Olive  oil  and  all  animal  fats  and  oils,  such  as  butter, 
cream,  cod-liver  oil,  bone  marrow.  Some  authorities,  however,  ex- 
clude all  fats.  Senator  objects  to  them  on  the  ground  that  they 
form  glycerin.  Cantani  excludes  butter  because  it  may  contain  some 
milk  sugar.  But  usually  such  rigidity  is  unnecessary.  In  some  dia- 
betic patients  the  power  of  fat  digestion  is  apparently  increased,  so 
that  they  tolerate  larger  quantities  than  in  health. 

Vegetables. — Spinach,  cress,  sorrel,  chicory,  rotnaine,  dandelions, 
beet  tops,  horseradish,  radishes,  celery,  sea-kale,  artichokes,  vegetable 
marrow,  okra,  lettuce,  endives,  pickles,  cucumbers,  gherkins,  cran- 
berries. The  following  vegetables  are  allowed  by  some  writers,  pro- 
hibited by  others  :  Green  French  string  beans,  asparagus,  summer 
■squash,  onions,  leeks,  carrots,  cauliflower,  cabbage,  sauerkraut,  cole- 
slaw, kohl-rabi,  parsley,  parsnips,  eggplant,  artichokes. 

Osier  says  that  because  potatoes  contain  somewhat  less  starch 
than  is  found  in  bread  they  may  sometimes  be  allowed  in  moderation 
when  the  latter  is  found  to  disagree.  Germain  S^e  gives  five  ounces 
of  potato  meal  daily  as  a  substitute  for  bread. 

The  following  statement  made  by  Fagge  is  useful  :  "  The  general 
rule  is  that  all  white  parts  of  vegetables  in  which  chlorophyll  has  not 


652 


DIET   IN    DISEASE. 


been  developed  by  exposure  to  sunlight  contain  no  sugar,  and  are  not 
harmful.  But  by  boiling  in  a  large  quantity  of  water,  even  the  forbid- 
den kinds  of  vegetables,  if  they  contain  sugar  only  and  not  starch,  may 
be  rendered  much  less  injurious."  There  is  a  decided  advantage  in 
using  such  green  vegetables  as  are  allowed  in  diabetic  diet  on  ac- 
count of  their  adding  to  the  bulk  of  waste  matter  in  the  intestine 
and  preventing  constipation,  which  almost  inevitably  results  from  a 
meat  diet. 

Miscellaneous. —  Kidneys,  tripe,  pig's  feet,  truffles,  mushrooms, 
sweetbreads,  terrapin. 

Cheese,  cream  cheese,  milk  curds. 

Jellies  made  of  gelatin,  calf's  foot,  with  wine,  but  unsweetened 
except  with  saccharin,  coffee  jelly,  lemon  jelly.  Van  Abbott  recom- 
mends an  ivory  jelly  made  from  ivory. 

Fruits,  if  acid,  not  sweet.  In  England,  where  gooseberries  are 
eaten  much  more  than  in  this  country,  they,  as  well  as  apples,  red 
currants,  and  sour  cherries,  are  sometimes  allowed.  Many  of  these 
fruits  contain  more  levulose  than  grape  sugar.  Sour  oranges,  lemons, 
grape  fruit,  olives,  sour  apples,  peaches  in  brandy  (without  sugar), 
raspberries,  and  strawberries  are  allowed  by  some,  but  are  usually 
forbidden.     Muskmelons  and  watermelons  may  sometimes  be  eaten. 

Nuts. — Oily  nuts,  such  as  almonds,  walnuts,  Brazil  nuts,  hazel- 
nuts, filberts,  pecan  nuts,  butternuts,  cocoanuts. 

The  articles  above  enumerated  afford  considerable  choice,  and  it 
is  to  be  distinctly  understood  that  only  so  many  of  them  are  to  be 
allowed  at  a  time  as  may  serve  to  divert  the  craving  of  the  patient 
from  his  chief  enemy — concentrated  hydrocarbons.  Some  patients 
will  be  found  who  can  eat  any  of  the  above  articles  with  impunity, 
while  others  can  take  but  very  few,  and  others  can  consume  certain 
foods  for  a  short  time  without  increasing  their  sugar  elimination, 
which  suddenly  will  be  found  to  agree  no  longer,  when  some  other 
food  must  be  at  once  substituted. 

It  is  apparently  true  that  there  are  some  individuals  for  whom  one 
or  two  articles  of  starchy  food  can  be  found  which  do  not  produce 
sugar  in  the  urine.  Fothergill  reports  several  cases  of  this  kind.  One 
of  his  patients  passed  urine  free  from  sugar  while  eating  vermicelli 
pudding  and  arrowroot.  Another  one  took  raspberry  jam  with  im- 
punity. When  such  cases  are  thoroughly  investigated,  however,  it  is 
usually  found  that  they  have  reached  an  intermittent  period  in  the 
activity  of  the  disease  which  is  not  infrequent  in  this  chronic  affec- 
tion, and  in  which  for  the  time  being  the  patient  is  very  much  better, 
and  the  urine  remains  for  a  little  while  practically  normal.  Such  in- 
stances occur  in  the  milder  types  of  cases. 

The  following  articles  are  absolutely 


DISEASES   ESPECIALLY   INFLUENCED    BY   DIET.  653 

Forbidden  Foods. 

Sugar  in  any  form — sirups,  molasses,  confectionery,  jams,  and 
sweets  of  all  kinds.  Honey  is  forbidden,  for  it  contains  both  dex- 
trose and  levulose. 

Starches. — All  the  elementary  forms  of  starchy  and  farinaceous 
food,  such  as  rice,  sago,  tapioca,  arrowroot,  oat  meal,  corn  meal,  hom- 
iny, samp,  buckwheat,  barley,  semolina,  macaroni,  spaghetti,  vermi- 
celli.  All  pastry,  cake,  puddings,  pies  of  every  description — in  short, 
everything  made  of  flour  excepting  a  little  bread  as  specified  above. 

Vegetables. — Potatoes,  beets,  carrots,  parsnips,  turnips,  peas,  beans 
(except  string  beans),  lentils,  cauliflower,  broccoli,  Brussels  sprouts, 
rhubarb.  Some  writers,  like  Dujardin-Beaumetz,  occasionally  allow 
a  well-baked  potato  in  mild  cases.  It  contains  only  15'/^  per  cent  of 
starch,  or  one  fifth  as  much  as  rice,  and  one  half  as  much  as  peas 
and  beans. 

Shellfish. — The  soft  parts  or  livers  of  clams,  oysters,  and  mussels 
contain  glycogen.  By  some  these  foods  are  entirely  forbidden,  but 
many  diabetic  patients  can  take  them  occasionally  without  injury. 

Liver  of  all  animals  (it  contains  g\ycog&n),  jt>dt^-de-/oie-gras. 

Fruits. — In  regard  to  the  use  of  fruits  there  is  some  difference  of 
opinion.  Sweet  fruits,  such  as  figs,  dates,  plums,  prunes,  bananas, 
apricots,  all  preserved,  candied,  or  sugared  fruits  must  be  absolutely 
interdicted.  Pears,  melons,  and  berries  are  forbidden  by  many,  but 
allowed  by  others. 

Nuts. — Chestnuts,  peanuts. 

Substitutes  for  Bread. 

After  all,  the  problem  for  selecting  a  suitable  starchy  food  for  the 
diabetic  is  governed  as  much  by  the  necessity  of  furnishing  some 
form  of  food  which  will  satisfy  the  craving  for  farinaceous  material 
as  for  the  actual  nourishment  which  it  may  contain. 

The  most  difficult  of  all  starchy  food  for  the  patient  to  forego 
is  bread.  Much  ingenuity  has  been  expended  in  attempts  to  devise 
substitutes  for  it,  and  many  preparations  for  making  artificial  breads, 
biscuits,  rusk,  or  cakes  with  eggs  and  butter  are  sold  in  market  for 
this  purpose.  Some  of  these  are  palatable  for  a  time,  but  many 
have  been  found  to  contain  60  or  80  per  cent  of  starch — fully  as 
much  as  wheaten  bread — while  others  contain  no  nutriment  at  all. 

Some  authorities,  as  Germain  S^e  and  Dujardin-Beaumetz,  advise 
giving  potato  meal  instead  of  bread,  five  ounces  per  diem,  which  may 
be  cooked  in  any  form  without  sugar. 

Terrified  starch  may  be  used  by  somCvdiabetics.  The  starch  is 
prepared  by  baking  a  large  ball  of  flour  so  thoroughly  that  the 
starch  granules  in  the  interior  of  the  mass  are  burst  open  by  the 


654 


DIET   IN   DISEASE. 


heat.  Terrified  bread  or  toast  consists  of  thin  cut  pieces  of  bread 
which  are  toasted  through  and  through  until  almost  black  before  a 
hot  fire  until  both  the  gluten  and  the  starch  are  disorganised  to  some 
extent.     Well-browned  bread  crust  is  of  the  same  nature. 

The  breads  made  from  flour  especially  prepared  for  diabetics 
are:  (a)  Gluten  bread;  (^)  bran  bread;  (c)  almond  bread;  {d)  inu- 
lin  bread ;  (e)  soya  bread. 

(a)  Gluten  Bread. — Gluten  bread  was  first  used  by  Bouchardat. 
It  is  made  by  washing  wheat  flour  in  such  a  manner  as  to  remove 
the  starchy  granules,  leaving  the  gluten  behind.  Such  bread  is  cer- 
tain to  contain  more  or  less  starch,  and  not  seldom  it  has  both 
starch  and  sugar.  It  is  much  more  tiresome  to  eat  than  any  ordi- 
nary bread,  and  unless  prepared  by  a  very  reliable  manufacturer  it 
has  little  to  recommend  it.  It  is  not  pleasant  to  masticate,  for  it  is 
often  unpleasantly  tough  and  stringy.  It  is  difficult  to  panify,  but  it 
may  be  aerated.  Gluten  biscuits  are  more  palatable  than  gluten 
bread,  but  most  of  these  preparations  have  the  disadvantage  of  not 
keeping  fresh  for  more  than  a  week  or  ten  days. 

6^/«/<?«y?i?;^r  is  used  for  thickening  broths,  egg  puddings,  etc. 

The  following  are  receipts  for  utilising  gluten  flour: 

Jeffries  s  Gluten  Biscuit  for  Diabetics. 

Gluten  flour I  cup. 

Best  bran,  previously  scalded i  cup. 

Baking  powder  (or  the  equivalent  of  bicarbonate  of  soda 

and  cream  of  tartar) I  teaspoonful. 

Salt to  taste. 

Eggs 2 

Milk  or  water i  cup. 

Mix  thoroughly. 

James  Stewart's  Diabetic  Bread. — "  Take  one  quart  of  sweet  milk 
or  milk  and  water,  one  heaping  teaspoonful  of  good  butter,  one  fifth 
of  a  cake  of  compressed  yeast  beaten  up  with  a  little  water,  and 
two  eggs  well  beaten.  Stir  in  gluten  flour  until  a  soft  dough  is 
formed,  knead  as  in  making  ordinary  bread,  put  in  pans  to  raise,  and 
when  light  bake  in  a  hot  oven." 

Liebig  proposed  to  prepare  bread  for  diabetics  by  pouring  a 
malt  infusion  over  thinly  sliced  wheaten  bread.  The  sugar  which 
is  thus  formed  is  washed  away,  and  the  gluten  residue  may  be 
eaten. 

It  is  very  difficult  to  obtain  a  reliable  gluten  flour.  Much  that 
is  sold  in  open  market  contains  more  starch  than  wheaten  bread — it 
may  hold  60  or  70  per  cent  (Harrington.) 

The  gluten  flour  obtained  in  the  market  in  London  or  Paris  con- 
tains about  15  per  cent  of  starch,  whereas  that  sold  in  the  United 
States  frequently  has  two  or  three  times  as  much. 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  655 

Tyson,  who  has  investigated  the  matter  thoroughly,  states  that 
the  gluten  breads  made  by  Theodore  Metcalf,  of  Boston,  and  the 
Sanitarium  Food  Company  of  Battle  Creek,  Michigan,  contain  less 
starch  than  other  American  preparations.  Pavy  recommends  a  glu- 
ten bread  and  biscuit  made  by  Bouthrou. 

A  wholly  starch-free  flour  does  not  exist. 

James  Stewart  gives  the  following  test  for  starch  to  be  applied 
to  gluten  flour:  A  little  of  the  flour  is  shaken  well  with  boiling 
water,  and  cooled.  A  few  drops  are  then  added  of  an  aqueous  solu- 
tion of  iodine  and  potassium  iodide  (Gram's  solution).  If  starch 
be  present,  a  decided  blue  colour  develops. 

Dujardin-Beaumetz  declares  that  gluten  bread  contains  more 
than  three  times  as  much  sugar-forming  material  as  potatoes,  and 
hence  he  prescribes  the  latter  instead. 

Van  Abbott  recommends  the  use  of  gluten  macaroni,  gluten  ver- 
micelli, and  gluten  semolina,  which  can  be  made  into  puddings  with- 
out sugar. 

Fromentine  is  another  form  of  diabetic  flour  made  from  wheat 
germs.  They  contain  less  starch  than  mature  wheat,  but  hold  an 
oil  which  is  purgative  and  which  prevents  proper  panification,  and 
causes  the  bread  to  sour  easily. 

Poluboskos  is  another  form  of  flour  said  to  contain  a  minimum 
of  starch. 

Embryonine  or  legumine  is  a  substance  isolated  from  the  casein 
of  legumes,  and  which  is  sometimes  given  for  diabetes. 

{b)  Bran  Bread. — The  use  of  bran  bread  was  first  suggested  by 
Prout,  but,  like  gluten  bread,  it  is  apt  to  contain  a  good  deal  of 
starch,  and  in  addition  tough  cellulose,  which  is  of  little  nutrient 
value  and  which  may  prove  irritating  to  the  mucous  membrane  and 
alimentary  canal,  causing  diarrhoea.  It  is,  moreover,  somewhat 
tasteless,  and  patients  quickly  tire  of  it.  Bran  bread  cakes  may  be 
purchased  prepared  expressly  for  the  use  of  diabetics.  They  are 
made  according  to  Dr.  Camplin's  receipt,  as  follows  : 

Camplitis  Bran  Bread. — "  Boil  one  quart  of  wheat  bran  in  two 
successive  waters,  wash  in  a  sieve  with  hot  water  until  the  water 
runs  through  clear.  Squeeze  in  a  cloth  after  each  washing.  Spread 
thinly  on  a  dish,  and  dry  in  slow  oven.  Grind  in  a  fine  mill,  and  sift 
by  brushing  through  a  very  fine  sieve.  Grind  the  residue  again  and 
sift.  Take  of  the  powder  three  ounces,  three  new  laid  eggs,  butter 
two  ounces,  and  half  a  pint  of  milk.  Mix  the  eggs  with  a  little  of 
the  milk,  warm  the  butter  with  the  rest.  Stir  the  whole  and  flavour 
with  nutmeg  or  ginger.  Bake  in  thin  cakes  in  a  quick  oven  for 
half  an  hour."  More  eggs  may  be  used,  and  Roberts  adds  sodium 
bicarbonate.  The  object  of  drying  the  bran  before  it  is  ground  is 
to  make  it  friable,  otherwise  it  is  too  soft  to  be  easily  powdered. 
44 


656  I^IET   IN   DISEASE.  ^ 

These  cakes  or  biscuits  may  be  eaten  with  butter  or  cheese,  and 
taken  with  meals  two  or  three  times  a  day. 

(c)  Almond  Cakes. — Pavy  first  suggested  the  use  of  almond  cakes 
for  diabetics,  which  he  prepared  by  making  a  meal  of  sweet  almonds. 
This  meal  when  washed  in  acidulated  water  is  freed  from  sugar,  and 
may  be  made  into  cakes  or  crackers.  Seegen  gives  the  following 
receipt  for  almond  cakes : 

Seegen' s  Almond-flour  Cakes. — "  Take  of  blanched  sweet  almonds 
a  quarter  of  a  pound,  reduce  to  powder  in  a  stone  mortar,  steep  in 
linen  in  boiling  water,  acidulated  with  vinegar,  for  fifteen  minutes 
to  remove  sugar.  Mix  the  paste  with  three  ounces  of  butter  and 
two  eggs,  add  the  yolks  of  three  eggs,  a  pinch  of  salt,  stir  well. 
Whip  the  whites  of  three  eggs  and  stir  in.  Put  the  dough  into 
greased  moulds,  dry  at  a  slow  fire.  Almond-flour  preparations  con- 
tain so  much  fat  that  they  often  prove  indigestible  after  a  few  days' 
trial,  and  they  are  relatively  expensive. 

Many  physicians  prefer  to  discard  the  use  of  all  substitutes  for 
bread,  such  as  bran  and  almond  cakes,  and  to  allow  the  patients 
a  limited  amount  of  plain  bread. 

(^)  Inulin  Bread. — A  form  of  bread  has  been  made  by  Kiilz 
from  inulin  and  lichinin.  Inulin  is  derived  from  the  root  of  elacam- 
pane  (Inula  helenium). 

Kiilz' s  Inulin  Biscuits. — "  Fifty  grammes  of  inulin  are  to  be  put 
in  a  large  porcelain  basin,  and  while  standing  over  a  water  bath  to 
be  rubbed  up  with  thirty  cubic  centimetres  of  milk,  and  as  much 
hot  water  as  may  be  necessary,  into  a  uniform  dough,  with  which 
the  yolks  of  four  eggs  and  a  little  salt  are  to  be  mixed.  To  this 
the  whites  of  four  eggs  are  to  be  added,  having  first  beaten  them 
to  a  foam  and  carefully  worked  them  in.  The  dough  is  finally  to  be 
baked  in  tin  moulds,  previously  smeared  with  butter.  The  taste  of 
the  biscuits  may  be  improved  by  the  addition  of  vanilla  or  other 
spices  "  (Dietary  of  the  Sick.  Von  Ziemssen's  Handbook  of  General 
Therapeutics).  These  biscuits  are  not  agreeable  to  the  taste  and 
patients  soon  tire  of  them. 

{e)  Soya  Bread. — A  meal  is  made  from  the  fruit  of  the  Soya  hispida, 
a  bean  which  is  grown  in  China  and  Japan  and  also  raised  in  Austria. 
It  is  very  rich  in  proteid.  It  has  a  peculiar  taste  and  holds  a  purga- 
tive oil. 

The  published  percentage  composition  of  the  more  important  in- 
gredients of  soya  bread  is  as  follows  : 

Water 45 .  000 

Proteids 20. 168 

Fats 9 .  350 

Starch  and  sugar 2 .  794 

Phosphoric  acid o.  863 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  657 

Soya  bread  is  nutritious  on  account  of  the  large  percentage  of 
fat  which  it  contains,  but  according  to  an  analysis  made  by  an  expert 
chemist  it  contains  more  carbohydrates  than  it  is  advertised  to  hold. 
This,  in  fact,  is  true  of  all  the  breads  and  biscuits  made  of  substi- 
tutes for  flour.  Prof.  Leeds  says  that  some  breads  which  are  falsely 
called  gluten  breads  contain  from  50  to  75  per  cent  of  carbohydrates, 
and  hence  they  are  unreliable  and  deceptive. 

Substitutes  for  Sugar.  ' 

Kulz  states  that  certain  of  the  sugars  and  allied  bodies  may  be  used 
with  the  food  without  increasing  the  glycosuria,  being  very  thoroughly 
consumed  within  the  body.  Such,  for  instance,  are  inulin,  inosite, 
mannite,  and  levulose  or  sugar  derived  from  fruits.  A  preparation 
of  the  latter  is  sold  under  the  name  of  diabetin. 

Glycerin  has  also  been  used,  but  Senator  and  Frerichs  are  op- 
posed to  it.  If  given  in  quantity,  such  as  one  or  two  ounces  a  day, 
it  occasions  intestinal  disorder,  and  may  prove  too  laxative.  It  also 
causes  a  continuous  sweet  taste  in  the  mouth. 

Within  the  past  few  years  saccharin  has  been  employed  with  suc- 
cess to  take  the  place  of  cane  sugar  for  sweetening  foods  for  dia- 
betic patients.  It  maybe  used  to  sweeten  coffee  and  other  materials. 
It  is  a  crystalline  nitrogenous  body  derived  from  coal  tar  which  is 
sparingly  soluble  in  cold  water,  more  soluble  in  hot  water,  and  very 
soluble  in  glycerin.  It  is  about  three  hundred  times  as  sweet  as  cane 
sugar,  and  when  taken  not  to  exceed  two  grains  daily  it  is  quite 
harmless.  Eaten  in  larger  quantity  it  disorders  digestion  and  causes 
gastric  pain.  A  convenient  formula  is  given  by  James  Stewart  for 
saccharin  pastilles  : 

Saccharin gr.  xlv. 

Sod.  bicarb,  sice 3  ss. 

Manniti 3  xijss. 

M.     Make  100  pastilles  ;  one  will  sweeten  a  cup  of  tea  or  coffee. 

Cooking. — Care  should  be  exercised  in  the  preparation  and  cook- 
ing of  the  food  for  diabetic  patients  that  injurious  ingredients  are 
not  added  for  the  purpose  of  flavouring  or  thickening.  For  this 
reason  all  the  articles  of  diet  should  be  cooked  as  simply  as  pos- 
sible, and  all  rich  sauces  containing  flour  should  be  forbidden. 
Melted  butter  may  be  used  as  a  substitute.  Roast  beef  should  not 
be  basted  with  flour,  and  meat  soups  must  not  be  thickened.  Vege- 
tables which  have  been  boiled  for  a  long  time  in  a  large  bulk  of 
water  have  most  of  their  sugar  dissolved  out,  and  on  that  account 
are  less  injurious. 

Very  acid  fruits  may  be  sweetened  with  saccharine  or  cooked 
with  a  little  sodium  or  potassium  bicarbonate  to  neutralise  their 
acidity. 


5e8  I5IET   IN   DISEASE. 

Beverages. 

Water. — It  is  an  important  matter  to  decide  to  what  extent  to 
restrict  the  quantity  of  water  and  other  fluids  drunk  by  diabeticg. 
When  so  much  urine  is  voided  that  the  patient's  rest  at  night  is  dis- 
turbed by  acts  of  frequent  micturition,  it  is  always  annoying,  and 
may  be  even  serious.  The  increased  work  thrown  upon  the  kidneys 
is  less  harmful  than  might  be  at  first  supposed,  for  the  water  of  the 
urine  is  excreted  chiefly  by  a  simple  process  analogous  to  filtration, 
which  no  doubt  taxes  the  renal  epithelium  less  than  the  excretion  of 
some  of  the  solids  of  the  urine.  At  all  events,  protracted  cases  of 
diabetes  do  not  necessarily  exhibit  serious  renal  degeneration. 

For  these  reasons,  if  the  water  drunk  is  restricted,  it  should  be  so 
more  on  account  of  relieving  the  patient  of  an  uncomfortable  con- 
dition than  from  fear  that  the  act  of  passing  so  much  urine  may  be 
injurious  per  se,  and  the  restriction  should  never  be  enforced  too 
suddenly.  As  a  rule,  when  dietetic  regulation  reduces  the  glycosuria 
and  improves  the  patient's  condition  there  is,  pari  passu,  a  reduction 
in  the  quantity  of  urine  voided.  In  other  words,  this  symptom  takes 
care  of  itself.  A  reasonable  restriction  of  the  fluids  allowed  is  to  be 
recommended,  but  when  thirst  is  extreme  it  becomes  unendurable 
torture  to  withhold  them  rigidly,  and,  moreover,  the  water  is  ap- 
parently needed  to  wash  out  the  sugar  which  would  otherwise  accumu- 
late in  the  blood  and  tissues.  In  fact,  the  occurrence  of  impcndmg 
coma  has  been  postponed  by  flushing  the  circulation  by  means  of 
large  draughts  of  water  or  enemata  of  salt  water. 

When  the  thirst  leads  to  excessive  drinking,  salt  foods  and  condi- 
ments should  be  withheld,  and  some  relief  may  be  obtained  by  suck- 
ing a  slice  of  lemon  or  by  using  a  liftle  potassium  bitartrate  and 
lemon  juice,  or  dilute  phosphoric  acid  in  water.  The  patient  should 
drink  only  from  a  small  glass,  for  there  is  more  satisfaction  in  drain- 
ing it  than  in  taking  the  same  quantity  of  fluid  from  a  large  goblet 
which  one  is  not  allowed  to  empty. 

The  meat  diet,  if  not  too  salt,  diminishes  the  desire  for  fluids  very 
much  as  compared  with  a  vegetable  diet,  for  usually  thirst  increases 
in  direct  proportion  to  the  amount  of  sugar  contained  in  the  blood. 

It  is  important  not  to  distress  the  patient  so  much  by  denial  that 
the  nervous  system  suffers  in  consequence. 

Beverages  forbidden. — As  a  rule,  patients  always  do  better  with- 
out alcohol,  and  strong  spirits  should  be  absolutely  interdicted  as 
well  as  sweet  and  sparkling  wines  of  every  kind,  all  wines  with 
"  bouquet,"  especially  Madeira,  port,  sweet  sherry,  Sauternes,  and 
champagnes.  No  punch  or  liqueurs,  cider,  beer,  ginger  or  sweet 
ales.  Soda  water  with  sirups  is  prohibited.  No  chocolate,  unless 
especially  prepared  without  sugar. 


DISEASES   ESPECIALLY   INFLUENCED    BY   DIET.  659 

Beverages  allowed. — If  it  becomes  necessary  to  give  alcohol  as  a 
tonic  or  stimulant,  an  acid  claret  or  Burgundy,  hock,  or  still  Moselle 
may  be  prescribed  diluted  with  mineral  water  ;  or  a  little  much-diluted 
brandy,  whisky,  or  unsweetened  gin  may  be  allowed.  Weak  brandy 
sometimes  allays  thirst  better  than  water.  Dry  sherry,  Chablis,  and 
Burton  bitter  ale  are  prescribed  occasionally,  and  the  California 
Riessling  or  Zinfandel  may  be  used.  Bass's  ale  may  be  allowed  be- 
cause the  sugar  which  it  originally  contained  has  been  entirely  con- 
verted into  alcohol  and  carbonic  acid  (Flint). 

Tea,  alone  or  with  lemon.  Coffee,  and  infusion  of  cocoa  nibs, 
sweetened  with  a  quarter  of  a  grain  of  saccharin,  are  allowed.  Choco- 
late may  be  manufactured  especially  without  sugar.  Buttermilk  may 
sometimes  be  given.  Sour  lemon  or  orange  juice  in  Vichy  with  a 
pinch  of  sodium  bicarbonate  makes  an  agreeable  and  cooling  draught. 
Saccharin  may  be  added. 

In  Germany  acorn  coffee  is  sometimes  used. 

As  an  adjunct  to  the  dietetic  treatment,  the  alkaline  mineral 
waters  are  extremely  serviceable,  especially  those  from  natural 
wells.  The  baths  and  waters  of  Carlsbad  and  Neuenahr,  Ems  in 
Germany,  and  Vichy  and  Contrexeville  in  France  have  achieved  a 
considerable  reputation  for  the  cure  of  diabetes,  and  after  making 
all  due  allowance  for  the  improvement  consequent  upon  proper 
regimen,  dietetic  regulation,  and  systematic  habits  of  life  which  are 
enforced  at  these  spas,  there  seems  to  be  special  benefit  derived  from 
the  waters  themselves.  Other  waters  which  may  be  drunk  are  Apol- 
linaris,  Johannis,  Saratoga  Vichy,  plain  soda  or  potash  water,  Seltzer, 
the  alkaline  calcic  Waukesha,  or  the  different  lithia  waters. 

SPECIAL   DIABETIC   DIETS. 

Skimmed  Milk. — An  exclusive  diet  of  skimmed  milk  was  first 
tried  by  Scott  Donkin.  At  first  a  gill  should  be  given  every  two  or 
three  hours,  or  from  six  to  eight  pints  daily,  to  be  increased  up  to 
twelve  pints.  The  small  amount  of  milk  sugar  contained  in  it  is 
said  to  do  no  harm  (Porteus,  Edinburgh  Medical  Journal,  xxx,  508- 
510).  Some  authors  advise  the  milk  diet  as  a  last  resort,  others 
recommend  trying  it  at  once.  Senator  says  that  the  sugar  of  milk 
does  not  increase  the  glycosuria,  and  undoubtedly  some  patients 
are  much  more  tolerant  than  others  of  the  sugar  of  milk. 

Tyson  says  it  is  harder  than  any  other  starchy  food  to  convert 
into  glucose  in  the  system.  He  recommends  giving  eight  ounces  of 
skimmed  milk  every  two  hours  between  7  a.  m.  and  7  p.  m.,  or  more 
if  necessary.  If  preferred,  the  curds  and  whey  may  be  separately 
taken. 

After  six  weeks  a  gradual  return  to  a  mixed  nitrogenous  diet 
may  be  permitted.     But  few  patients,  however,  can  be  found  to  ac- 


56o  I^IET   IN   DISEASE. 

custom  themselves  to  this  diet  or  to  endure  it  for  more  than  two  or 
three  days.  Koumiss  has  been  successfully  substituted  for  the 
skimmed  milk.  In  it  the  milk  sugar  is  already  converted  into 
alcohol. 

Buttermilk  is  sometimes  given,  and  like  koumiss  it  allays  the 
thirst  to  some  extent.  The  milk  sugar  has  been  converted  into 
lactic  acid. 

By  many  writers,  as  Dujardin-Beaumetz  and  Flint,  milk  in  any 
form  is  prohibited,  while  others  recommend  its  use  in  moderation 
while  a  rigid  diet  of  proteid  and  fat  must  be  adhered  to. 

Ebsteins  Diabetic  Diet. 

Early  Breakfast. — One  cup  of  coffee  or  tea  (black),  without  milk 
and  sugar.  White  bread  toasted,  thirty  to  fifty  grammes ;  or  brown 
bread  well  buttered — butter,  twenty  to  thirty  grammes.  The  yolk  of 
an  ^g^,  a  little  fat  ham,  or  some  German  sausage,  if  required.  If 
any  food  be  needed  between  this  meal  and  dinner,  let  it  be  a  cup  of 
broth,  with  the  yolk  of  an  ^"g^. 

Dinner. — Broth,  with  yolk  of  t%%  or  marrow  (the  marrow  bone  is 
boiled  for  half  an  hour,  to  solidify  the  marrow).  Peptone  may  be 
added  to  the  broth.  Meat,  one  hundred  and  eighty  grammes,  free 
from  bone,  roasted,  boiled,  or  stewed — beef,  mutton,  pork,  veal,  fowl, 
or  venison  (fat  meat  preferred).  Gravies,  to  be  made  with  cream 
or  yolk  of  t,%%,  not  flour.  Fish  to  be  served  with  melted  butter. 
Vegetables  prepared  with  much  fat ;  purees  of  leguminous  plants  ; 
salads,  dressed  with  vinegar  and  oil.  The  food  should  be  well 
salted  and  spiced.     After  dinner,  a  cup  of  coffee  or  tea. 

Supper. — One  cup  of  tea  or  broth.  Meat  (roasted),  or  cheese,  or 
^n  ^zz,  or  fish,  caviare.  Bread,  thirty  to  fifty  grammes,  with  butter, 
twenty  to  thirty  grammes.  Apples,  pears,  and  stone-bearing  fruits 
are  allowed  in  small  quantities. 

Beverages. — Ebstein  forbids  absolutely  the  use  of  beer,  limits  the 
use  of  spirits,  and  allows  about  half  a  bottle  of  wine  daily.  If  the 
patient  can  digest  milk  well,  it  is  allowed  in  moderate  doses,  and 
cream  is  especially  recommended. 

In  the  following  diet,  recommended  by  During,  it  will  be  noticed 
that,  contrary  to  some  other  symptoms,  fat  is  excluded  as  much  as 
possible. 

During  claims  that  prolonged  boiling  so  alters  the  carbohydrates 
as  to  prevent  them  from  being  eliminated  in  the  urine  as  sugar,  and 
he  gives  his  patients  a  diet  consisting  largely  of  rice  and  fruits 
which  have  been  soaked  in  water  and  boiled  for  several  hours.  The 
details  of  his  regimen  are  as  follows  : 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  66l 

Daring's  Diet  for  Diabetes. 

Early  Breakfast. — Milk,  with  a  little  coffee  but  no  sugar  (lime 
water,  to  prevent  milk  from  souring  in  the  stomach) ;  stale  white 
bread  ad  libitum.,  or,  if  it  is  not  well  borne,  oatmeal,  barley,  or  rice 
gruel  made  with  water,  a  little  salt,  but  no  butter. 

Second  Breakfast. — White  bread,  stale  and  well  baked  ;  an  tg%, 
lightly  boiled  ;  rice  or  oatmeal  gruel,  with  or  without  milk,  a  break- 
fast-cup full ;  or  half  a  glass  of  good  red  wine  (with  water  in  certain 
cases). 

Dinner  (taken  between  two  and  three  o'clock). — Soup,  with  rice, 
barley,  or  oatmeal ;  meat,  roasted,  two  hundred  and  fifty  grammes 
(game,  ham,  and  smoked  meats,  as  free  from  fat  as  possible,  are 
permissible);  no  condiments,  no  fatty  sauces;  compote  of  dried 
apples,  plums,  cherries;  dried  peas  or  white  beans  in  some  cases; 
green  vegetables,  asparagus,  French  beans,  carrots,  cauliflower, 
cabbage  (boiled  in  water  with  salt,  not  with  fat  or  stock) ;  dessert 
of  a  little  raw  fruit,  apples,  cherries,  and  one  small  glass  of  red  wine 
diluted  with  water. 

Supper  (about  7  P.  M.). — Gruel  of  barley,  oatmeal,  or  rice,  with 
salt  (but  no  butter),  and  strained.  In  some  cases  may  be  made  with 
milk.     Ice  or  iced  water,  to  relieve  thirst  between  meals. 

JVaunyn's  Diet. 

Naunyn  divides  diabetes  somewhat  arbitrarily  into  three  varieties 
— mild,  severe,  and  intermediate.  For  the  most  severe  cases  he 
gives  a  diet  of  fat  meat ;  the  intermediate  cases  are  treated  at  first 
on  an  exclusive  diet  of  fat  meat,  then,  as  the  sugar  disappears  from 
the  urine,  he  adds  eggs,  milk,  and  a  small  allowance  of  bread  to  the 
diet.  In  mild  forms  he  directs  the  use  of  a  few  green  vegetables, 
salads,  fruits,  and  other  articles,  unless  the  sugar  reappears  in  the 
urine,  when  the  patient  is  to  be  put  back  upon  a  rigid  nitrogenous 
diet.  He  claims  that  in  mild  cases  of  diabetes  patients  do  not  re- 
quire more  than  from  sixteen  to  eighteen  ounces  of  meat  a  day,  with 
two  or  three  ounces  of  bread  and  six  or  seven  ounces  of  vegetables. 

Hygienic  Treatment. — Patients  should  guard  themselves  as 
far  as  possible  from  catching  cold,  and  when  possible  should  live  in 
a  moderately  warm  and  temperate  climate.  If  their  surroundings 
permit,  it  is  important  to  take  moderate  exercise  and  to  remain  in 
the  open  air.  Flannels  should  be  worn  next  to  the  skin  in  winter, 
and  the  body  should  always  be  kept  warm,  for  there  is  less  heat-pro- 
ducing power  than  normally.  The  skin  should  be  maintained  in 
good  condition  by  frequent  warm  baths  pr  hot  and  cold  douching, 
dry  rubbing,  or  massage.  All  muscular  and  nervous  or  mental 
fatigue  is  to  be  avoided.     It  is  claimed  by  KUlz  that  muscular  exer- 


662  I^IET   IN   DISEASE. 

cise  tends  to  increase  the  consumption  of  sugar  or  glycogen  in  dia- 
betes and  to  lessen  its  elimination  by  the  kidneys.  This  applies  to 
the  more  robust  cases  only,  for  in  the  severe  type  of  the  disease 
with  great  emaciation  much  exercise  becomes  harmful  or  impossible. 

Medicinal  Treatment. — The  medicinal  treatment  of  diabetes  is 
exceedingly  unsatisfactory.  In  a  certain  proportion  of  cases  of  dia- 
betes cure  may  result  by  exclusive  dietetic  treatment.  There  are 
others  in  which  the  use  of  medicines  is  found  to  be  of  some  service, 
but  it  may  be  stated  positively  that  there  are  no  cases  which  are 
curable  by  medicines  without  proper  dietetic  treatment. 

Opium  and  codeia  are  successful  in  some  instances  in  reducing 
the  amount  of  sugar.  Commencing  with  half-grain  doses,  the  latter 
is  to  be  gradually  increased  until  ten  or  fifteen  grains  are  taken  in  a 
day  ;  alkalies,  such  as  the  citrate  and  acetates,  are  also  occasionally 
found  beneficial.  Clemen's  liquor  arsenici  bromati  has  attained  suc- 
cess in  some  hands.  Digestive  tonics,  aromatic  bitters,  mineral  acids, 
and  cod-liver  oil  are  frequently  indicated,  and  strychnine  and  ergot 
are  to  be  employed  as  vasomotor  tonics  when  desired.  They  regulate 
the  arterial  tension,  and  may  reduce  the  quantity  of  urine  and  re- 
lieve the  thirst. 

The  nitrogenous  diet  is  apt  to  excite  diarrhoea,  which  may  be 
controlled  by  such  remedies  as  salol,  salicylate  of  bismuth,  or  cas- 
tor oil. 

For  the  intense  craving  for  food  experienced  by  some  patients, 
with  a  hollow,  sinking  feeling  at  the  epigastrium,  Roberts  recom- 
mends a  two-  or  three-grain  asafoetida  pill  three  times  a  day. 

Scrofula. 

Causation. — Scrofula  is  not  a  distinct  disease,  having  definite 
lesions  and  symptoms,  but  is  rather  a  diathesis  resulting  from  mal- 
nutrition, accompanied  by  chronic  inflammations  of  the  skin,  mucous 
membrane,  bones  and  joints,  and  a  tendency  to  caseation  or  suppura- 
tion of  the  lymphatic  glands.  The  majority  of  cases  which  were  for- 
merly classified  as  scrofulous  are  now  regarded  as  belonging  either 
to  tuberculosis  or  hereditary  syphilis.  Scrofulous  children  easily 
succumb  to  tuberculosis  whenever  a  few  tubercle  bacilli  gain  en- 
trance to  the  lungs  or  other  organs,  and  they  should  therefore  be 
especially  protected  against  such  infection. 

The  scrofulous  condition  is  favoured  by  impure  hygienic  sur- 
roundings, foul  air,  dark,  damp,  and  poorly  ventilated  apartments, 
by  overcrowding,  and  insufficient  and  improper  diet.  Infants  nursed 
at  the  breast  of  a  healthy  mother  or  wet  nurse  are  far  less  apt  to 
develop  scrofulous  symptoms  than  if  they  are  fed  upon  artificial 
infant  foods.  A  diet  of  coarse  starchy  foods,  such  as  oatmeal,  black 
rye  bread,  corn  .lieal,  farina,  or  potatoes,  all   containing  insufficient 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  663 

nitrogenous  material,  is  always  an  important  influence  in  the  develop- 
ment of  this  diathesis.  Such  food  tends  to  increase  the  fat  and  water 
in  the  tissues  at  the  expense  of  albuminous  substances. 

Dietetic  Treatment. — The  indications  for  dietetic  treatment 
are  accordingly  to  supply  the  patient  with  food  which  contains  a 
large  relative  proportion  of  fat  and  nitrogen.  In  this  manner  the 
easily  overtaxed  and  enfeebled  digestive  power  is  benefited.  Starchy 
food,  while  not  in  itself  injurious,  becomes  so  from  the  fact  that  it 
must  be  eaten  in  very  large  bulk  in  order  to  furnish  enough  nitrogen 
for  the  needs  of  the  growing  child.  Milk,  eggs,  or  meat  must  there- 
fore be  substituted  for  it,  and,  when  possible,  the  food  may  to  ad- 
vantage consist  for  some  weeks  exclusively  of  milk,  which,  if  neces- 
sary, should  be  predigested  and  Pasteurised. 

The  analysis  and  proper  modification  of  milk  to  suit  the  needs  of 
scrofulous  children  is  so  much  better  understood  at  present  than 
formerly  that  breast  feeding  in  these  cases  is  not  as  essential  as  it 
used  to  be,  although  it  is  to  be  recommended  unless  the  mother  or 
wet  nurse  is  herself  scrofulous.  In  the  latter  case  her  milk,  on 
analysis,  will  be  found  deficient  in  fat  and  proteid. 

The  infant  should  be  carefully  weighed  every  few  days,  for  this 
furnishes  the  best  guide  as  to  the  rate  of  food  assimilation. 

A  distinction  is  sometimes  made  in  the  diet  of  scrofulous  children 
according  to  the  two  distinct  types  of  the  disease — namely,  the  ery- 
thitic  or  sanguine,  and  the  torpid  or  phlegmatic  variety.  Children  of 
the  former  type  are  fair  and  delicate,  with  transparent  skins  and 
blue  veins.  The  muscles  are  soft,  the  bones  are  slender,  and  the 
weight  is  light.  The  teeth  appear  early,  the-  nervous  system  is 
irritable,  and  the  mind  is  acute.  Such  children  require  abundant 
fatty  food.  Infants  of  this  type  require  above  4  per  cent  of  fat 
in  their  food,  and  cream  must  be  added  if  the  milk  is  poor,  unless 
they  show  a  tendency  to  become  too  fat,  when  it  may  be  temporarily 
reduced  in  quantity.  Older  children  may  be  given  half  an  ounce  of 
cream  several  times  a  day,  or  other  forms  of  fat,  such  as  butter  and 
cod-liver  oil.  They  often  dislike  fat,  but  it  is  even  more  necessary 
for  them  than  albuminoids,  and  they  may  usually  be  got  to  take  it 
in  some  form  or  other.  They  should  be  allowed  no  starches  except 
stale  bread,  crackers,  or  toast. 

Children  of  the  phlegmatic  type  are  stout,  thick-set,  and  clumsy. 
The  skin  is  coarse,  the  expression  is  dull  and  heavy.  The  abdomen 
and  digestive  organs  are  large.  The  pulse  is  feeble.  There  is  over- , 
production  of  subcutaneous  fat,  and  there  is  a  tendency  to  catarrhs 
of  the  mucous  membranes,  to  eczema,  and  to  enlargement  of  the 
cervical  lymphatic  glands.  These  children  need  plenty  of  good 
animal  food — milk,  beef,  etc. — and  should  not  be  given  coarse 
cereals  or  much  fat. 


664 


DIET   IN   DISEASE. 


All  dietetic  treatment  of  the  scrofulous  condition  is  materially- 
aided  by  good  hygienic  surroundings.  Outdoor  country  life  and 
either  sea  bathing  or  mountain  air  is  strongly  to  be  recommended. 
Special  pains  must  be  taken  to  prevent  constipation,  which  is  apt 
to  exist  as  a  chronic  habit  because  of  the  faulty  diet,  which  has 
been  too  large  in  bulk.  Cod-liver  oil  or  bread  and  molasses  may 
serve  to  prevent  it. 

Rhachitis  (Rickets). 

Causation. — Rickets  is  a  disease  of  malnutrition.  The  fault 
may  lie  in  a  hereditary  weakness  of  the  digestive  organs,  or  the 
influence  of  some  disease,  but  the  majority  of  cases  are  directly 
caused  by  improper  or  insufificient  food.  This  food  may  be  the 
breast  milk  of  a  mother  or  wet  nurse,  who  is  herself  enfeebled  by 
chronic  disease,  by  oft-repeated  pregnancies,  or  whose  mammary  se- 
cretion is  modified  by  dietetic  errors — loss  of  sleep,  emotional  or 
neurotic  disorders,  or  the  milk  supply  may  simply  be  insufficient 
from  too  long-continued  nursing  or  the  intervention  of  pregnancy, 
or  some  other  factor.  The  poor,  for  reasons  of  economy,  often 
suckle  their  children  for  too  long  a  period — in  fact,  until  they  are 
two  years  of  age — but  even  before  weaning  them  they  allow  them  to 
go  to  the  table  and  share  in  the  general  diet  of  fried  fish,  pickles, 
potatoes,  pork,  raw  fruits,  beer,  etc.  Children  treated  in  this  man- 
ner are  especially  prone  to  develop  rickets. 

In  all  doubtful  cases  the  milk  of  the  mother  or  nurse  should  be 
analysed  before  the  child  is  weaned,  and  an  effort  should  be  made  to 
improve  its  quality:  If  the  child  is  already  weaned,  the  cause  of 
the  rickety  condition  ma}'  be  a  poorly  selected  diet,  such  as  a  patent 
"baby  food,"  with  insufficient  fat  and  earthy  salts  and  excess  of 
starch. 

Rickets  has  been  experimentally  produced  by  Cheadle,  Guerin, 
and  others  in  young  animals  by  depriving  them  of  animal  fats  and 
earthy  salts.  It  is  caused  by  withholding  all  lime  salts  from  the 
food  (Voit),  but  especially  calcium  phosphate,  and  young,  growing 
animals  failing  to  receive  a  fresh  supply  absorb  lime  salts  from 
bones  already  ossified  for  the  benefit  of  the  newer  ones,  and  thus 
all  the  bones  become  soft.  Baginsky  found  that  this  process  is  ex- 
aggerated in  young  animals  by  the  presence  of  lactic  acid  in  the 
food,  and  Wegner  proved  that  phosphorus  has  a  similar  effect. 
Forster  has  calculated  from  the  lime  ordinarily  present  in  milk 
that  an  infant  four  months  of  age  receives  about  a  gramme  each 
day. 

Starchy  and  saccharine  foods  not  only  contain  little  or  none  of 
the  necessary  lime,  but  easily  undergo  lactic-acid  fermentation,  which 
it  has  just  been  shown  intensifies  the  rhachitic  processes. 


DISEASES   ESPECIALLY    INFLUENCED   BY   DIET. 


665 


Leeds  and  Davis  believe  that  the  prolonged  use  of  milk  sterilised 
at  a  very  high  temperature  predisposes  infants  to  the  development  of 
rickets. 

Prophylaxis. — The  best  prophylactic  against  rickets  in  any 
child  is  nursing  through  the  first  year  at  the  breast  of  a  healthy 
mother  or  of  a  carefully  selected  wet  nurse. 

It  is  a  very  common  practice  in  this  country  for  mothers,  on  one 
pretext  or  another,  to  wean  their  babies  too  early,  and  without  a 
physician's  advice  to  resort  to  one  of  the  much-advertised  patent  in- 
fant foods,  with  the  result  above  described. 

Dietetic  Treatment. — The  dietetic  treatment  of  rhachitis  in  a 
weanling  must  consist,  first  of  all,  in  supplying  good  fresh  cow's 
milk  modified  to  resemble  as  closely  as  possible  the  best  mother's 
milk.  It  is  highly  important  that  the  milk  should  contain  sufficient 
fat,  and  it  must  be  modified  accordingly  by  the  addition  of  cream  or 
oil  (see  Modified  Milk,  page  78). 

If  the  child  must  be  bottle  fed,  the  milk  should  be  carefully  Pas- 
teurised in  order  to  diminish  the  liability  of  its  fermentation  in  the 
alimentary  canal,  and  among  the  poor,  who  cannot  afford  to  pur- 
chase prepared  milk  in  this  way,  the  milk  as  soon  as  purchased 
should  be  heated,  and  a  few  grains  of  bicarbonate  of  sodium  may  be 
added  to  it.  A  plug  of  previously  baked  cotton  should  be  used  in 
the  bottle  in  place  of  a  cork.  When  given,  the  milk  should  be  di- 
luted with  barley,  water,  or,  if  constipation  is  present,  with  oatmeal 
water.  These  waters  are  made  by  boiling  a  tablespoonf  ul  of  pearl  bar- 
ley or  of  good  oatmeal  in  a  pint  of  water  until  the  meal  is  completely 
softened.  A  little  salt  is  then  added,  and  the  mass  is  strained 
through  a  fine  cloth.  It  is  advisable  also  to  add  milk  sugar.  The 
proportion  of  milk  for  the  diluent  should  be  half  and  half  for  the 
first  six  weeks  of  infancy  ;  after  this  the  proportion  is  to  be  gradu- 
ally increased,  and  when  six  months  of  age  it  should  be  given  three 
parts  milk  and  one  part  diluent.  The  quantity  of  milk  is  to  be  con- 
tinuously increased,  and  at  the  ninth  month  it  may  be  in  the  propor- 
tion of  four  to  one,  and  at  the  end  of  the  year  dilution  is  no  longer 
required. 

Very  young  infants  who  are  fed  by  artificial  means  should  not  ■ 
be  given  any  farinaceous  food.  In  the  first  two  or  three  months  of 
infant  life  the  saliva — from  deficiency  in  ptyalin — is  incapable  of 
digesting  starch,  and  starch  is  also  poorly  digested  by  the  pancreatic 
juice  in  the  intestine.  Starch,  therefore,  acts  as  a  foreign  body  and 
a  gastro-intestinal  irritant,  and  passes  through  the  alimentary  canal 
unaltered. 

It  is  advisable  in  all  rickety  children^  to  restrict  the  giving  of 
farinaceous  foods  until  some  time  after  the  period  when  they  are 
often  allowed,  and,  as  a  rule,  children  having  rickets  should  not  be 


656  I^IET    IN    DISEASE. 

fed  any  starchy  food  until  after  the  twelfth  or  fourteenth  month. 
They  need  fats  much  more  than  starches  or  sugars. 

There  are  some  apparent  exceptions  to  this  where  infants  be- 
come seemingly  robust  while  fed  upon  amylaceous  foods  at  a  very 
early  period,  but  they  are  less  healthy  as  they  grow  older  or  exhibit 
malnutrition  or  some  constitutional  weakness.  Such  exceptions  by 
no  means  controvert  the  value  of  the  rule  in  general,  as  above 
stated.  When  starchy  food  is  given  to  young  infants  it  should  al- 
ways be  predigested  with  diastase  or  "malted." 

Preparations  of  condensed  milk  which  contain  large  quantities 
of  sugar  are  sometimes  given  to  infants  by  mothers,  and  they  pro- 
duce a  prompt  increase  in  weight,  but  the  appearance  in  these  cases 
is  deceptive,  and  the  muscles  and  other  tissues  are  less  firm  and 
strong  than  they  should  be.  This  is  proved  by  the  fact  that  chil- 
dren erroneously  fed  in  this  way  succumb  far  more  easily  to  various 
diseases  of  infancy,  especially  to  diarrhoeal  troubles,  which  they  may 
acquire  later  on.  After  the  first  year  a  little  of  some  malted  or  pre- 
digested form  of  starchy  food  may  be  added  to  the  milk. 

Whenever  amylaceous  food  is  mixed  with  the  milk  it  should  be  pre- 
viously converted,  as  far  as  possible,  into  dextrin  or  glucose,  and  it 
should  be  added  rather  with  the  object  of  mechanically  preventing 
the  formation  of  coagulae  of  casein  than  with  the  idea  of  feeding  the 
infant  upon  a  substance  which  its  digestive  organs  are  not  yet  fitted 
to  act  upon.  J.  Lewis  Smith  says  :  "  If  a  heaping  teaspoonful  of  barley 
flour  be  boiled  in  twenty-five  teaspoonfuls  of  water,  and  when  it  is 
lukewarm  ten  or  fifteen  drops  of  diastase  (Forbes)  be  added  to  it, 
the  gruel  in  a  few  minutes  becomes  much  thinner  from  the  digestion 
of  starch,  and  it  is  a  useful  adjuvant  to  the  milk  employed  in  the 
nursery,  especially  for  infants  over  the  age  of  six  months."  At  this 
time  or  later  a  little  albuminous  food  in  the  form  of  mutton  or 
chicken  broth  dr  the  expressed  juice  of  rare  roast  beef  or  beefsteak. 

After  a  year  or  fourteen  months  the  diet  should  consist  of  cow's 
milk,  cream,  beef  juice  squeezed  from  a  fresh  steak,  and  broths,  and 
stale  bread  crumbs  in  milk  may  be  added.  Later  still,  the  child  may 
take  scraped  beef  or  a  raw  beef  sandwich  made  with  thin  layers  or 
bread  and  butter  with  meat  pulp  between  them.  Beef  tea,  mutton,  and 
chicken  broths  are  good.  A  little  fresh  fruit  juice,  especially  orange 
juice,  is  excellent.  A  little  sweet  currant  jelly  added  to  the  meat 
will  improve  its  flavour  for  older  children  who  object  to  taking  it. 
When  a  year  and  a  half  old  the  child  may  be  given  eggs,  either 
beaten  with  milk  and  sweetened  or  soft-cooked.  If  attacks  of  diar- 
rhoea supervene,  it  will  be  well  to  stop  the  meat  broths  temporarily 
and  put  the  child  for  a  few  days  on  a  diet' of  koumiss,  matzoon,  or 
pancreatinised  milk.  In  some  cases  maltine  is  found  to  agree  well 
with  rhachitic  children,  and  if  diarrhoea  does  not  exist  they  should 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  667 

be  given  pure  Norwegian  cod-liver  oil  three  times  a  day  in  doses  of 
a  few  drops  for  a  young  infant,  up  to  a  teaspoonful  for  a  child  a 
year  or  two  old.  Older  children  should  have  abundant  fat,  in  the 
form  of  fresh  butter  on  bread,  or  cream  upon  stewed  fruit  or  baked 
apples.  Fothergill  wrote  :  "  The  liquid  fat  of  fried  bacon  is  most 
digestible,  and  the  child  should  be  allowed  to  dip  its  bread  in  it  or 
have  it  crumbed  into  the  fluid  fat."  Or  it  may  occasionally  be  given 
a  piece  of  bacon  to  suck. 

The  fat  of  bone  marrow  might  be  used  for  the  same  purpose. 
Inunctions  of  two  or  three  teaspoonfuls  of  olive  oil  may  be  given 
daily  over  the  legs  and  abdomen. 

Rhachitic  children,  on  account  of  their  poor  nutrition,  usually  have 
a  deficient  number  of  teeth  or  their  teeth  are  imperfect  or  quickly 
decay.  It  is  therefore  important  that  when  they  have  passed  the 
first  dentition  food  should  always  be  given  them  in  a  state  of  fine 
subdivision,  otherwise  it  will  be  bolted  without  mastication  and 
gastro-intestinal  disorder  will  result.  Meat  should  be  thoroughly 
hashed  or  pounded  in  a  mortar,  and  solid  meat  should  never  be  given 
the  child  to  masticate  until  it  is  over  two  years  of  age.  Potatoes 
should  only  be  given  baked  in  a  soft  and  mealy  form. 

Some  breast-fed  infants  may  become  rickety,  while  others  badly 
fed  by  artificial  means  may  not,  and  the  extraordinary  instances  of 
toleration  of  improper  food  which  one  constantly  finds  among  the 
children  of  the  ignprant  poor,  at  times  severely  test  one's  faith  in  die- 
tetic rules,  but  much  allowance  must  be  made  for  the  constitution  of 
individuals  and  for  race  characteristics.  The  subsequent  history  of 
wrongly  fed  children  often  points  directly  to  original  faults  in  diet 
which  have  affected  the  general  nutrition  of  the  body,  although  the 
immediate  effect  of  such  errors  may  not  have  been  apparent. 

AIDS   TO   DIETETIC   TREATMENT. 

Rhachitic  babies,  as  well  as  older  children,  should  be  weighed  at 
regular  intervals  as  an  important  guide  for  their  correct  feeding. 

In  rickets  more  or  less  gastric  catarrh  is  commonly  present, 
which  interferes  with  normal  digestion  and  absorption,  and  appropri- 
ate medicinal  remedies  should  be  employed  to  regulate  this  condi- 
tion when  necessary.  There  is  often  excessive  acidity  in  the  stom- 
ach which  must  be  neutralised  by  sodium  bicarbonate.  The  hygienic 
treatment  of  the  children  in  conjunction  with  dietetic  measures  is  of 
the  utmost  importance.  Rickety  children  must  practically  live  out- 
doors in  all  .seasonable  weather,  and  it  is  better  for  them  to  remain 
out  in  fresh,  cold  air  than  to  be  kept  at  home  in  a  damp,  dark,  over- 
heated, and  badly  ventilated  tenement.  They  should  be  frequently 
bathed  in  order  to  keep  the  skin  in  as  good  condition  as  possible, 
and  prevent  the  occurrence  of  skin  diseases,  which  are  a  common 


658'  DIET    IN   DISEASE. 

accompaniment  of  malnutrition.  They  should  be  kept  quiet  and 
not  worried,  and  if  they  are  weak  and  feeble,  great  care  should  be 
exercised  in  handling  them  and  in  placing  them  in  proper  positions 
upon  beds  which  are  firm  but  not  hard,  in  order  to  prevent  the  .weak; 
ened  bones  from  becoming  deformed. 

Scurvy.  >     ^^(\ 

-^^  -  -^ 

Causation. — Scurvy  is  a  disease  dependent  upon  malnutrition, 
which  is  customarily  attributed  to  lack  of  fresh  vegetables  in  the 
dietary ;  but  this  statement  is  somewhat  vague,  in  that  it  is  not  ex- 
actly known  which  articles  of  diet  are  most  liable  to  produce  the 
disease  by  their  absence,  although  many  believe  that  the  cause  is 
due  to  deficiency  of  salts  whose  acids — citric,  malic,  lactic,  acetic, 
and  tartaric — form  carbonates,  but  no  preventive  food  has  been 
found  which  is  absolutely  successful  in  all  cases.  At  all  events,  it  is 
a  disease  due  to  omission  and  not  to  consumption  of  certain  foods, 
and  it  depends  rather  upon  the  quality  than  quantity  of  food.  In 
opposition  to  the  theory  that  the  want  of  fresh  vegetables  acts  as  a 
cause  of  scurvy  in  a  man,  the  fact  is  stated  by  Lieutenant  Greely 
that  among  the  Danish  Eskimos,  who  have  a  population  of  ten  thou-, 
sand,  not  a  pound  of  vegetables  nor  a  dozen  pounds  of  bread  per 
man  are  eaten  annually,  and  yet  they  are  practically  free  from  the  dis- 
ease, and  the  same  statement  is  made  in  regard  to  the  most  northern 
tribes  of  Eskimos  of  pure  blood  who  were  studied  by  Lieutenant 
Peary,  and  also  in  regard  to  the  natives  of  the  Alaskan  archipelago 
and  some  tribes  of  North  American  Indians  who  do  not  include 
either  vegetables  or  bread  in  their  food.  It  is  an  undoubted  fact 
that  the  disease  is  much  oftener  present  among  people  who  have 
lived  for  some  time  in  bad  hygienic  surroundings  and  in  damp, 
dirty  quarters,  and  who  have  been  subjected  to  mental  depression, 
monotony  of  occupation  and  diet,  or  excessive  work  and  fatigue,  as 
well  as  the  abuse  of  alcohol.  It  has  often  been  known  in  prisons. 
It  is  therefore  possible  for  scurvy  to  occur  in  any  part  of  the  world 
among  men  affected  by  these  conditions,  but  it  is  much  less  common 
at  the  present  time  than  formerly. 

In  the  British  arctic  expedition  of  i875-'76  over  48  per  cent  of 
the  men  suffered  from  scurvy,  and  a  still  larger  percentage  existed 
among  those  who  were  exempt  from  field  service  and  outdoor  life. 

When  the  potato  crop  failed  in  Great  Britain  and  Ireland  in  1846 
scurvy  became  very  prevalent.  In  the  war  of  the  Grimea  twenty- 
three  thousand  cases  occurred  among  the  French  troops  alone. 

Woodruff,  referring  to  scurvy  in  the  United  States  Army,  writes  : 
"  If  transportation  is  so  deficient  that  only  bacon,  hard-tack,  and 
coffee  can  be  carried,  actual  scurvy  is  the  result.  The  company 
commander  must  secure  something  else  for  his  men.     The  lack  of 


DISEASES   ESPECIALLY   INFLUENCED   BY   DIET.  669 

fresh  vegetables  and  fresh  meat  is  the  chief  fault.  Why  fresh  things 
are  needed  is  not  known,  but  it  is  believed  to  be  due  to  the  fact  that 
the  body  thus  received  certain  salts  and  unknown  substances  neces- 
sary as  stimulants  or  tonics  to  the  tissues,  which  salts  and  substances 
are  destroyed  by  the  usual  methods  of  preservation.  It  is  not  to  be 
denied  that  men  may  live  for  many  years  without  tasting  such  articles 
of  diet,  though  it  is  rare  for  a  man  to  be  denied  all  three — meats,  fresh 
vegetables,  and  fresh  fruits.  If  they  are  so  denied  they  are  not  pos- 
sessed of  that  health  which  permits  of  the  highest  mental  and  physi- 
cal development." 

Scurvy  contributed  15  per  cent  to  the  death  rate  from  diseases 
in  the  late  civil  war,  and  it  was  formerly  prevalent  among  seafaring 
men  when  upon  long  voyages,  who  lived  upon  salt  pork  or  pickled 
meats;  but  the  disease  is  encountered  much  less  often  at  the  present 
time,  owing  to  the  better  means  of  preserving  foods,  securing  variety 
in  diet,  and  better  hygiene.  The  regulations  of  boards  of  trade 
usually  require  that  antiscorbutic  foods  and  remedies  should  be 
carried  upon  vessels,  and  the  development  of  scurvy  on  board  ship, 
unless  in  exceptional  cases  of  shipwreck  or  in  voyages  prolonged 
beyond  the  expected  limit,  subjects  the  captains  or  owners  to  indict- 
ment for  criminal  negligence.  The  English  law  early  required  that 
lime  juice  should  be  carried  on  long  voyages,  and  this  formerly 
earned  the  nickname  of  "  lime  juicers  "  for  British  sailors. 

Many  almshouses  have  similar  regulations. 

Scurvy  has  been  known  to  occur  from  failure  of  intestinal  absorp- 
tion, in  which  case  it  is  less  easily  preventable. 

Garrod  holds  that  scurvy  is  caused  by  absence  of  potash,  for^in 
this  disease  the  blood  is  deficient  in  potassium  salts.  He  regards 
this  fact  also  as  an  explanation  of  the  muscular  weakness  which 
is  a  prominent  feature,  and  observes  that  all  good  antiscorbutics — 
fresh  milk,  meat,  lemons,  and  fresh  vegetables — contain  abundant 
potash. 

Garrod's  theory  is  modified  by  Immermann,  who  believes  that  a 
temporary  lack  of  these  salts  may  cause  trophic  disorders,  which  may 
continue  for  some  time  after  the  deficiency  in  salts  has  been  made 
good,  and  Duchek  has  even  found  that  in  exacerbations  of  symp- 
toms occurring  in  scurvy  there  may  be  an  increased  elimination  of 
potash  salts  in  the  urine.  The  body  is  capable  of  retaining  and  re- 
using its  various  salts  for  a  considerable  time,  so  that  withdrawal  of 
the  potash  does  not  necessarily  induce  scurvy  at  once  (Bauer). 

Northrup  and  Crandall  recently  investigated  the  causes  of  scurvy 
in  a  number  of  infants,  and  report  that  they  find  the  employment  of 
proprietary  foods  which  for  various  reasons  are  substituted  by  the 
mother  for  fresh  food  is  the  most  important  cause  of  scurvy,  and 
"even  fresh  milk  in  small  proportions  is  not  sufficient  to  insure  per- 


6/0 


DIET    IN   DISEASE. 


fection."     Their  report  continues  (New  York  Medical  Journal,  May 
26,  1894)  : 

"  The  exact  diet  is  known  in  thirty-three  cases.  We  find  that 
twelve  of  these  children  (;i6  per  cent)  were  fed  on  a  proprietary  food 
exclusively,  six  (18  per  cent)  had  received  an  exclusive  diet  of  con- 
densed milk  or  evaporated  cream,  while  three  received  a  combination 
of  these  two  foods.  Over  6^  per  cent,  therefore,  were  fed  upon  a 
diet  of  proprietary  foods  and  condensed  milk.  Two  children  re- 
ceived sterilised  milk  exclusively,  and  three  a  weak  mixture  of  milk 
and  water.  One  was  fed  on  condensed  milk,  one  on  boiled  and  pep- 
tonised  milk,  and  one  on  barley  water." 

"  It  is  a  significant  fact  that  the  country  which  furnishes  most 
of  the  literature  of  scorbutus  in  children  is  the  same  which  is 
posted  from  end  to  end  with  advertisements  of  proprietary  foods  " 
(Northrup). 

Prophylaxis. — So  long  as  the  hygienic  conditions  are  good  and 
the  food  is  of  the  best  quality  and  variety,  and  if  proper  discipline 
and  regular  habits  of  eating  and  sleeping  are  insured,  scurvy  may  be 
prevented  among  soldiers  and  sailors,  although  fresh  vegetables  may 
not  be  obtainable. 

The  introduction  of  canned  and  compressed  vegetables  in  sea- 
men's rations  has  done  much  to  prevent  scurvy,  but  fresh  food  is 
always  to  be  preferred  for  this  purpose  to  preserved  food  of  any 
kind  when  it  can  be  obtained.  Dried  legumes  are  quite  useless. 
For  travellers  in  the  far  North,  Nordenskiold  advises  the  use  of 
cloud  berries  {^Rubus  chamcBmorus). 

„  Dietetic  Treatment. — In  mild  cases  of  scurvy  of  comparatively 
short  duration  patients  rapidly  improve  under  proper  dietetic  treat- 
ment if  it  can  be  obtained.  The  juice  of  two  or  three  limes  or 
lemons,  or  a  few  fresh  vegetables  eaten  daily,  may  be  all  that  is 
necessary,  and  the  former  is  one  of  the  best  preventives  as  well  as 
curative  agents. 

A.  E.  Wright  dissents  from  this  view  (British  Medical  Journal, 
July,  1894,  p.  57),  at  least  in  regard  to  such  cases  as  may  suffer 
from  bleeding  from  the  gums.  He  claims  that  the  acids,  tartaric 
and  citric,  have  a  decided  inhibitory  action  upon  intravascular  coagu- 
lation when  given  per  os,  and  maintains,  contrary  to  general  experi- 
ence, that  in  scurvy  with  persistent  haemorrhage  the  use  of  fresh 
lemon  juice  tends  to  keep  up  the  oozing  of  the  blood.  He  says  that 
the  neutral  citrates  and  tartrates  do  not  act  in  this  manner,  and  they 
should  therefore  be  prescribed  instead  of  fresh  lemon  juice. 

Stomatitis  is  often  the  most  prominent  symptom,  and  if  the 
mouth  is  very  tender,  the  gums  are  swollen  and  bleed  readily,  and 
the  stomach  is  irritable,  the  diet  must  be  limited  to  fluid  or  some 
solid  food  which  requires  no  mastication.      Beef   tea,    broths  and 


MISCELLANEOUS   DISEASES.  67 1 

meat  soups  thickened  with  vegetables,  fresh  vegetable  purees,  eggs, 
and  milk  are  recommended.  To  these  substances  the  juice  of  two 
or  three  fresh  oranges,  limes,  or  lemons  should  be  added.  If  the  pa- 
tient is  able  to  masticate  food  thoroughly,  and  the  stomach  is  not 
too  feeble,  fresh  meat,  baked  or  mashed  potatoes,  cabbage,  sauer- 
kraut, pickles,  salad,  and  "greens,"  such  as  water  cress,  fresh  mus- 
tard, or  radishes,  may  be  given.  The  citrate  of  iron,  vinegar,  acetic 
acid,  and  potassium  chlorate  and  bitartrate  have  all  proved  benefi- 
cial. During  the  War  of  the  Rebellion  the  expressed  juice  of  sor- 
ghum was  tried  with  some  success. 

The  treatment  of  scurvy  in  children  consists  first  in  throwing 
away  all  proprietary  foods,  and  then  if  the  disease  has  not  pro- 
gressed too  far,  improvement  and  cure  rapidly  follow  change  to  a 
normal  diet  of  mother's  milk  or  fresh  cow's  milk,  expressed  beef 
juice,  and  a  little  fresh  orange  or  peach  juice. 

H.^MORRHAGIC    PURPURA. 

With  regard  to  idiopathic  purpura,  which  sometimes  appears  in 
well-nourished  subjects,  it  has  been  stated  that  a  non-stimulating 
diet,  by  reducing  the  activity  of  the  heart,  may  prevent  the  recur- 
rence of  haemorrhages.  Bauer  says:  "Such  patients  should  take  all 
foods  and  drinks  cool,  and  never  in  large  quantities  at  a  time  ;  they 
should  abstain  altogether  from  alcohol,  and  milk  is  to  be  recom- 
mended for  its  easy  tpleration  in  these  cases." 


MISCELLANEOUS    DISEASES. 

Addison's  Disease. 

The  aetiology  of  this  affection  is  still  obscure,  it  being  by  some 
regarded  as  a  blood  disease,  by  others  as  a  condition  depending 
upon  irritation  of  the  sympathetic  nervous  system  produced  by  a 
lesion  of  the  adrenals  involving  the  abundant  nerve  supply  of  those 
structures.  Some  cases  show  tubercular  degeneration  of  the  ad- 
renals. 

At  first  no  dietetic  treatment  is  required,  but  in  advanced  cases 
there  is  always  weakness  of  the  digestive  system,  and  vomiting  may 
be  a  common  symptom.  There  is  also  progressive  inanition,  which 
becomes  extreme.  The  diet,  therefore,  must  be  of  a  light  and  easily 
digestible  character.  In  some  of  the  advanced  cases  the  best  re- 
sults are  obtained  from  an  exclusive  milk  diet.  For  others,  when 
milk  is  not  well  borne,  the  diet  should  consist  of  beef  or  mutton 
broth,  with  eggs  beaten  with  milk  or  sherry,  gruels  with  added 
milk  extracts  or  peptonoids,  custard,  rennet,  milk  toast. 

Nourishment  should  be  given  at  short  intervals,  at  least  once 
45 


6/2 


DIET   IN   DISEASE. 


in  three  hours,  and  the  patient  should  be  encouraged  to  take  all 
that  he  can  possibly  digest.  The  intermittent  vomiting  may  neces- 
sitate the  use  of  nutrient  enemata.  Wine  or  spirits  are  usually 
required  for  tonic  and  stimulant ,  effect ;  the  special  variety  is  im- 
material. 

Osteomalacia. 

The  dietetic  treatment  of  the  condition  of  osteomalacia  is  sug- 
gested by  what  is  known  of  its  aetiology,  but  the  results  are  seldom 
encouraging.  It  is  characterised  by  progressive  softening  of  the 
bones,  a  disease  in  which  the  salts,  especially  the  carbonate  and 
phosphate  of  lime,  are  reduced  to  about  30  per  cent  of  the  normal 
■quantity. 

It  is  not  definitely  known  in  what  manner  these  salts  are  dis- 
solved out  of  the  bony  structures,  and  excess  of  both  lactic  and 
carbonic  acid  have  been  regarded  as  probable  solvents.  It  is  not 
proved  that  a  deficiency  of  salts  in  the  diet  causes  the  disease, 
which  has  been  observed  in  well-fed  subjects.  It  is,  however,  cus- 
tomary to  arrange  the  diet  with  regard  to  furnishing  an  abundance 
of  salts  together  with  such  articles  as  milk,  eggs,  and  meat. 

It  is  advisable  also  to  prescribe  cod-liver  oil,  either  alone  or  in 
combination  with  various  phosphates  or  hypophosphites,  and  this 
food  proves  on  the  whole  the  most  serviceable.  Trousseau  thought 
that  it  cured  one  or  two  of  his  cases. 

It  is  a  rare  affection  in  its  worse  type,  although  cases  of  moderate 
severity  are  less  uncommon. 

Exophthalmic  GoItre. 

It  is  only  very  advanced  cases  of  exophthalmic  goitre  with 
considerable  cardiac  palpitation  that  require  careful  dieting.  The 
indications  for  treatment  are  to  support  the  strength  and  avoid 
flatulency  and  constipation,  and  any  substances  liable  to  increase 
palpitation  or  excite  the  nervous  system  must  be  withheld. 

Stimulants  of  all  kinds  should  be  avoided.  Tea,  coffee,  alcohol, 
condiments,  and  tobacco  are  all  forbidden,  as  are  also  sugar,  sweets, 
pastry,  fried  food,  and  "  made  dishes." 

The  food  should  be  plainly  cooked,  and  should  consist  of  abun- 
dant meats,  milk,  fats  (such  as  cream,  butter,  and  cod-liver  oil),  care- 
fully prepared  cereals,  fresh  fruits,  and  green  vegetables. 

Chronic  Lead  Poisoning. 

Causation. — Chronic  lead  poisoning  is  common  among  all  arti- 
sans or  mechanics  who  work  with  much  lead  in  any  form,  but  espe- 
cially white  lead.  Plumbers  and  house  painters  are  therefore 
^particularly   subject    to    it.      It    may   also    be   acquired  by    eating 


MISCELLANEOUS   DISEASES. 


^3 


improperly  tinned  Or  badly  soldered  canned  food,  although  such 
cases  are  usually  acute.  It  is  sometimes  caused  by  using  drinking 
water  which  has  passed  through  new  lead  pipes.  When  present  in 
the  strength  of  only  one  one-hundredth  of  a  grain  to  the  gallon  it 
may  cause  palsy. 

The  cheap  ale,  or  "  four  ale,"  as  it  is  called,  sold  in  London  to 
the  lowest  classes,  is  sometimes  kept  in  contact  with  pewter  pipes 
until  it  contains  toxic  quantities  of  lead. 

Lead  is  sometimes  contained  in  poisonous  amount  in  beer  or 
wine  which  has  been  contaminated  by  the  metal  during  its  careless 
manufacture.  Some  persons  are  exceedingly  susceptible  to  lead, 
and  cases  are  recorded  of  poisoning  from  the  medical  use  of  a  few 
doses  of  lead  and  opium  pills,  and  also  from  that  of  cosmetics  con- 
taining white  lead. 

Dietetic  Treatment. — Chronic  lead  poisoning  is  nearly  always 
accompanied  by  constipation,  and  it  is  highly  important  to  over- 
come this  difficulty  by  such  foods  as  will  keep  the  bowels  actively 
open.  Fresh  fruits  and  coarse  cereals  (such  as  oatmeal,  corn  meal, 
wheaten  grits,  Graham  bread),  and  molasses  are  recommended,  with 
.such  other  foods  and  regulations  as  are  given  under  the  heading  of 
the  Treatment  of  Constipation  (page  548). 

Water  should  be  drunk  in  large  quantity,  not  only  to  increase 
the  digestive  secretions  and  keep  the  faeces  moist,^  but  to  act  as  a 
diluent  and  aid  in  washing  out  the  poison. 

Lemonade,  acidulated  with  dilute  sulphuric  acid,  fifteen  drops  to 
the  tumblerful,  or  with  a  similar  dose  of  aromatic  sulphuric  acid,  is 
much  in  vogue  as  a  prophylactic  beverage,  for  it  forms  an  insoluble 
lead  sulphate  from  the  more  soluble  carbonate  or  other  salts  of 
lead  which  may  have  reached  the  stomach  by  being  taken  with  food 
or  drink.  This  insoluble  salt  is  not  absorbed,  and  hence  poisoning 
may  be  averted. 

Men  employed  in  the  manufacture  of  white  lead  or  other  prep- 
arations of  lead  believe  that  drinking  milk  freely  as  a  beverage  is 
prophylactic  against  poisoning,  but  it  is  doubtful  whether  it  acts 
otherwise  than  as  a  good  diuretic. 

Lead  colic  is  sometimes  benefited  by  gastric  lavage  (Kussmaul, 
Riesland). 

Dietetic  Complications  arising  from  Associated 

Diseases. 

There  are  certain  diseases  and  conditions  which  are  not  infre- 
quently associated  in  the  same  individual,  the  dietetic  treatment  of 
each  of  which  may  be  directly  opposed  to  fhat  of  the  other.  Such, 
for  example,  are :  Diabetes  and  chronic  Bright's  disease,  the  former 
requiring  chiefly  meat,  the  latter  none ;  extreme  leanness  and  chronic 


674 


DIET   IN   DISEASE. 


gastric  catarrh,  the  former  condition  requiring  fats,  starches,  and  su- 
gars, the  latter  prohibiting  them ;  obesity  and  chronic  albuminuria,  the 
former  requiring  animal  food,  the  latter  none  (unless  it  be  milk); 
acute  rheumatism  and  extreme  anaemia,  the  former  requiring  no  solid 
animal  food,  the  latter  demanding  it ;  intestinal  dyspepsia  and  gall- 
stones, the  former  benefited  by  a  meat  diet  and  no  starches  or  veg- 
etables, the  latter  doing  better  with  opposite  diet ;  ascites  and  chronic 
albuminuria,  where  the  quantity  of  fluid  ingested  as  well  as  the  diet 
may  present  very  opposite  requirements. 

When  such  complications  arise  it  is  possible  to  compromise  for  a 
time  upon  a  milk  diet,  this  being  the  most  natural  food,.and  one 
which,  on  the  whole,  is  capable  of  more  universal  adaptation  than 
any  other.  In  other  cases,  as,  for  example,  in  the  first  instance  men- 
tioned above — of  diabetes  accompanied  by  severe  Bright's  disease — 
one  must  be  governed  by  the  patient's  general  condition,  the  gain  or 
loss  of  body  weight,  the  strength  of  pulse  and  muscle  tone  being  the 
important  guides  for  one  or  other  system  of  dieting.  The  lesser 
evil,  whichever  it  may  be,  must  naturally  give  way  to  the  greater, 
and  a  generous  mixed  diet  may  sometimes  be  found  to  serve  the 
patient  better  than  one  too  much  restricted  by  theoretical  consid- 
erations. 

No  subject  taxes  the  skill  and  ingenuity  of  the  dietist  more  se- 
verely than  the  treatment  of  such  complications,  when  ordinary  rules 
.appear  most  contradictory. 


DIET  FOR  SURGICAL  PATIENTS  AND  AFTER 
OPERATIONS,  ETC. 

Food  and  Anesthetics. 

Preparation  for  the  Administration  of  Anaesthetics. — When 
an  anaesthetic,  such  as  ether  or  chloroform,  is  to  be  given,  care  should 
be  exercised  that  the  stomach  is  empty,  otherwise  vomiting  is  apt  to 
occur  at  a  critical  moment  when  the  patient  is  weak,  and,  being  uncon- 
scious, the  natural  reflexes  of  the  process,  including  the  closure  of 
the  epiglottis,  are  not  well  carried  out,  and  food  is  very  easily  drawn 
into  the  trachea  and  excites  serious,  if  not  fatal,  choking.-  For  this 
reason  the  patient  is  usually  prepared  for  the  anaesthetic  by  giving 
a  light  and  easily  digested  breakfast,  consisting  largely  of  milk  with, 
perhaps,  a  little  farinaceous  food,  and  three  or  four  hours  later  the 
anaesthetic  may  be  administered  with  safety. 

Feeble  patients  sometimes  require  an  ounce  of  brandy  or  whisky 
half  an  hour  before  the  operation — long  enough  before  for  it  to 
become  absorbed. 

It  is  never  desirable  to  give  an  anaesthetic  within  three  hours 


SURGICAL   PATIENTS   AND   AFTER   OPERATIONS. 


675 


khet  the  ingestion  of  a  full  meal.  It  impedes  anaesthetisation,  be- 
sides causing  the  danger  of  vomiting  and  choking.  In  many  cases  it 
is  better  to  allow  five  or  six  hours  to  intervene.  In  an  emergency 
where  an  accident  occurring  shortly  after  a  heavy  meal  requires  the 
immediate  use  of  anaesthesia,  it  may  be  well  to  give  an  emetic  first 
for  the  purpose  of  completely  unloading  the  stomach  while  the  pa- 
tient is  conscious. 

The  instances  of  fatal  choking  from  vomiting  and  aspirating  food 
into  the  larynx  are  fortunately  rare,  as  they  are  preventable,  but 
they  are  by  no  means  unknown.  Since  their  occurrence  is  almost 
always  due  to  negligence  on  the  part  of  the  anaesthetiser  for  not 
observing  proper  precautions,  they  are  inexcusable.  Ether,  by  some 
specific  action,  is  more  likely  than  chloroform  to  prove  irritating 
and  excite  vomiting  while  being  inhaled.  When  retching  is  violent 
it  may  be  sometimes  overcome  by  "crowding  "  the  anaesthetic — that 
is,  by  causing  it  to  be  inhaled  more  energetically  for  a  moment,  until 
reflex  irritation  is  overcome. 

Diet  after  Anaesthesia. — Ether,  much  more  than  chloroform, 
is  apt  to  occasion  prolonged  nausea  and  vomiting  after  its  adminis- 
tration has  ceased,  and.  this  may  last  in  very  susceptible  persons  for 
a  day  or  two.  In  all  cases  where  ether  is  employed  to  produce  pro- 
found narcosis,  even  when  only  used  to  assist  physical  examinations 
diagnostic  purposes,  it  is  well  that  caution  should  be  observed  for 
some  hours  afterwardsSn  giving  food,  and  a  light  fluid  diet  of  milk, 
beef  tea,  or  a  cup  of  cocoa,  tea,  or  coffee  only  should  be  allowed 
when  any  tendency  to  nausea  or  vomiting  exists.  Under  ordinary 
circumstances  no  food  is  required  until  the  effects  of  the  anaesthetic 
have  mainly  passed  off,  and  with  continued  gastric  irritation  it  is 
necessary  to  confine  the  patient  to  a  fluid  diet  for  twenty-four  hours 
or  more,  and  give  but  little  of  that.  If  the  patient  has  been  much 
exhausted  by  haemorrhage  during  the  operation  or  by  prolonged 
anaesthesia,  nourishment  may  be  sometimes  given  sooner,  but  in 
concentrated  predigested  form.  Brandy  and  soda  is  useful  under 
these  conditions,  and  often  allays  gastric  irritation.  Very  hot  water 
is  to  be  recommended  for  the  same  purpose.  In  cases  of  laparotomy 
for  operations  upon  any  part  of  the  alimentary  canal,  such  as  ap- 
pendicitis, it  may  prove  best  to  give  the  digestive  organs  entire 
physiological  rest  for  twenty-four  hours  at  least,  but  if  the  pa- 
tient is  in  need  of  nourishment  one  or  two  food  enemata  may  be 
given. 

The  following  schedule  of  diet  for  the  day  may  be  taken  as  an 
example  for  an  ordinary  operation  under  anaesthesia : 

7  A.  M. — A  cup  of  beef  tea,  coffee,  or  cocoa,  or  a  cup  of  bread 
and  n^lilk. 

II  A.  M. — Anaesthesia  and  operation. 


676 


DIET   IN   DISEASE. 


3  P.  M. — Iced  milk  and  Vichy,  beef  essence,  or  peptonoids.  If 
vomiting,  hot  water,  or  one  half  to  one  ounce  of  brandy  with  soda. 

y  P.  M. — Bread  and  milk,  or  beef  jelly,  or  cocoa  and  a  biscuit. 
Nothing  more  until  the  next  day,  when,  if  there  are  no  special  reasons 
to  the  contrary  from  existing  disease  or  complications  arising  from 
the  operation,  the  patient's  previous  customary  diet  may  be  grad- 
ually resumed. 

Diet  after  Surgical  Operations  and  Injuries. 

Fractures,  wounds,  bruises,  ulcers,  and  all  surgical  injuries  natu- 
rally heal  the  sooner  the  better  the  condition  of  the  blood.  Abun- 
dant nourishing  diet,  properly  selected  in  regard  to  its  ready  digesti- 
bility, is  therefore  indicated.  Starvation  promptly  impoverishes  the 
blood  and  retards  all  healing  processes. 

Mild  Cases. — In  feeding  surgical  patients  who  are  confined  to 
bed  or  who,  from  the  nature  of  their  injuries,  are  unable  to  exercise, 
care  should  be  taken  that  the  channels  for  removal  of  waste  from 
the  body  do  not  become  choked  and  inert.  In  the  zeal  to  promote 
rapid  healing  by  a  liberal  diet  it  is  quite  possible  to  overcharge  the 
blood  with  products  of  nutrition  and  defeat  the  object  in  view  by 
burdening  the  liver  and  other  organs,  and  inducing  "biliousness." 

The  patient's  appetite  should  not  be  the  only  guide,  but  the  con- 
dition of  the  tongue,  the  stools,  and  the  urine  should  be  examined  to 
insure  the  proper  assimilation  of  all  the  food  taken.  In  the  absence 
of  sepsis,  fever,  and  all  affections  of  the  alimentary  canal  there  is 
usually  no  harm  in  allowing  the  full  diet  of  animal  and  vegetable 
food  to  which  the  patient  is  normally  accustomed,  or,  if  the  appetite 
flags,  considerable  variety  in  the  dietary  may  be  advantageously  per- 
mitted. 

If  there  has  been  no  loss  of  blood  and  no  severe  shock,  as  soon 
as  an  ordinary  antiseptic  operation  is  over  the  patient  is  practically 
as  well  as  he  was  before  it  was  performed. 

Cheyne  says:  "After  operations  performed  aseptically  there  is 
no  reduction  of  diet  even  for  a  few  days.  A  hospital  patient  remains 
on  full  diet,  and  a  private  patient  may  have  anything  he  fancies,  pro- 
vided it  is  wholesome,  and  the  more  nutritious  the  food  the  better." 
In  fact,  after  opening  a  psoas  abscess  or  a  carious  joint  the  appetite 
soon  returns  and  "hunger  becomes  the  chief  trouble." 

As  a  rule,  stimulants  are  unnecessary  if  the  appetite  is  keen,  but 
otherwise  beer  or  Burgundy  or  dilute  whisky  may  be  prescribed  in 
moderation  as  an  aliment,  to  be  taken  with  the  meals  only.  Hard 
drinkers  who  receive  bad  injuries,  such  as  severe  fractures,  fre- 
quently develop  delirium  tremens  in  the  course  of  a  few  days,  and 
this  may  occur  even  when  they  have  not  been  indulging  in  stimu-- 
lants  for  some  weeks  previously.     la  such  cases  it  may  become  ne- 


SURGICAL   PATIENTS   AND   AFTER   OPERATIONS.  677 

cessary  to  allow  a  certain  quantity  of  alcoholic  stimulation  at  stated 
intervals  between  meals,  in  order  to  tide  them  over  an  emergency 
which  threatens  an  immediately  fatal  result,  trusting  to  reduce  the 
quantity  as  the  delirium  subsides. 

Severe  Cases. — If  severe  pain  has  preceded  an  operation,  if  the 
operation  has  been  prolonged,  or  if  there  has  been  much  shock,  even 
under  anccsthesia,  the  diet  must  be  supervised  with  great  care.  Pain 
is  a  strong  depressant,  and  after  severe  shock  rest  and  stimulation  is 
usually  more  desirable  than  food.  Positive  harm  results  from  over- 
feeding. Black  coffee  is  very  serviceable  for  such  cases  or  whenever 
there  is  lack  of  nerve  energy,  and  it  may  be  necessary  to  keep  the 
patient  for  three  or  four  days  upon  a  diet  of  milk  or  pancreatinised 
milk.  Broths,  meat  extracts,  and  beaten  eggs  may  be  added  when 
the  stomach  regains  its  tone.  If  nausea,  anorexia,  or  disgust  for 
food  exists,  or  if  there  is  much  distention  of  the  stomach,  it  is  un- 
wise to  urge  food  upon  the  patient.  It  is  better  to  utilise  the  rectum 
in  such  cases,  and  coffee,  pancreatinised  milk,  egg  albumen,  and 
alcohol  are  to  be  given  in  enemata.  Opium  or  other  necessary  medi- 
cation may  be  added. 

If  extensive  loss  of  blood  has  occurred,  the  volume  of  fluid 
should  be  replaced  in  the  body  as  soon  as  possible,  and  liquid  food 
is  needed,  such  as  milk,  beef  broths,  peptonoids,  and  brandy  or 
whisky,  if  the  stomach  retains  them.  Salt-water  injections,  or  in 
severe  cases  hypodermic  injections  of  saline  solutions,  help  restore 
the  lost  fluid  to  the  blood  and  improve  vascular  tone. 

It  was  noticed  long  ago  that  persons  past  middle  life  who  were 
of  full  habit  and  addicted  to  excesses  at  the  table  or  in  drink  were 
more  apt  to  suffer  from  septicaemia  after  sustaining  a  compound 
fracture  or  an  amputation  than  thinner,  more  abstemious  subjects. 
This  observation  led  to  the  practice  of  keeping  these  patients,  and 
the  former  class  especially,  for  a  protracted  period  upon  a  very  meagre 
diet;  but  it  proved  to  be  a  mistaken  view,  for  suppuration,  inflam- 
mation, and  fever  are  all  exhausting  processes,  accompanied  by  in- 
creased tissue  waste,  which  must  be  compensated  by  abundant 
nutritious  food,  and  whether  plethoric  or  spare,  the  patient  must  be 
well  fed. 

Diet  after  Laparotomy,  Ovariotomy,  etc. 

After  all  operations  involving  opening  the  peritoneal  cavity 
complete  rest  ot  the  stomach  is  necessary  for  at  least  four  or  six 
hours,  and  not  infrequently  for  two  or  three  days.  Food  and  stimu- 
lants may  be  given  by  enemata  (page  375).  If  fed  />er  os  for  the 
first  three  days  not  over  a  tablespoonful  of  pancreatinised  milk  or 
milk  with  lime  water  or  barley  water  should  be  allowed  once  in  two 
cr  three  hours.     Later  the  quantity  may  be  increased  and  the  inter- 


6/8 


DIET   IN    DISEASE. 


vals  diminished,  and  beef  tea,  beef  peptonoids,  and  egg  albumen  may 
be  added. 

In  these  cases  the  duration  of  anaesthesia  has  usually  been  pro- 
longed, and  the  shock  is  considerable.  The  danger  from  the  occur- 
rence of  vomiting,  malfermentation  of  food,  and  flatulent  distention 
of  the  abdomen  is  far  worse  than  that  of  inanition  from  absti- 
nence. 

After  wounds  and  operations  affecting  the  stomach  or  intestines 
no  food  at  all  should  be  given  by  the  mouth.  Nothing  but  a  little 
cracked  ice  should  be  so  administered,  and  all  nourishment  must  be 
supplied  for  several  days  by  the  rectum.  The  return  to  mouth  feed- 
ing must  be  made  very  slowly  and  cautiously  by  at  first  giving  not 
over  one  or  two  tablespoonfuls  of  pancreatinised  milk  or  beef  ex- 
tract at  a  time. 

There  is  often  much  thirst  following  operations  involving  the 
peritonaeum,  which  is  relieved  more  by  hot  fluids  than  by  ice,  which 
sometimes  irritates  the  throat  and  increases  the  desire  for  drink.  If 
there  is  danger  of  all  fluids  exciting  emesis,  a  salt-water  enema  once 
in  three  or  four  hours  will  alleviate  thirst  (page  36). 

Diet  in  Surgical  Inflammations,  Sepsis,  etc. 

The  diet  in  surgical  inflammatory  conditions  was  formerly  re- 
duced to  a  minimum,  with  the  idea  that  the  healing  process  would 
be  more  sure  if  the  stimulating  influence  of  food  was  removed,  and 
that  the  inflammation,  like  an  infectious  fever,  should  be  "starved 
out."  The  dief  adso/ue,  a.s  the  French  surgeons  of  the  first  half  of 
this  century  termed  it,  meant  virtual  starvation,  barley  water,  arrow- 
root water,  or  toast  water  being  all  that  was  allowed.  With  im- 
provement in  feeding  fevers  came  a  change  in  the  diet  of  inflamma- 
tory conditions,  and  it  was  recognised  that  the  waste  of  tissue 
material  and  the  expenditure  of  force  in  the  evolution  of  heat  must 
be  replenished  by  nutritious  food.  No  one  to-day  starves  pneu- 
monia, nor  yet  does  an  intense  local  inflammation  of  a  joint  demand 
that  the  patient  should  have  solid  meat  meals,  but  there  is  an  appro- 
priate mean  to  be  observed  between  overfeeding  and  starvation. 
After  operations  inflammation  will  not  be  avoided  by  starving,  and 
the  patient's  strength  must  rather  be  supported  by  easily  assimilable 
food.  In  all  acute  inflammatory  conditions  tissue  waste  is  rapid 
and  appetite  and  digestive  power  are  lessened. 

In  severe  cases  a  diet  of  milk,  diluted  by  one  third  or  one  half 
with  Vichy  or  Seltzer  water,  may  be  given,  four  ounces  every  hour 
and  a  half  or  six  ounces  every  two  hours.  Other  articles  should  be 
added,  such  as  expressed  beef  juice  or  beef  peptonoids.  These  sub- 
stances may  at  first  be  given  alone,  and  then  added  to  strong  beef,' 
mutton,  or  chicken  broth.     Gruels  of  arrowroot  or  oatmeal,  raw 


SURGICAL   PATIENTS   AND   AFTER   OPERATIONS.  679 

eggs  alone,  or  beaten  and  added  to  sherry  or  brandy,  custard,  milk 
puddings,  and  beef  jelly  are  all  recommended. 

When  improvement  occurs,  a  light  convalescent  diet  may  be  pre- 
scribed, such  as  that  found  on  page  395.  Acidulated  drinks,  sour 
lemonade,  oatmeal  or  barley  water,  and  effervescing  waters  may  be 
used  to  relieve  thirst. 

In  mild  cases,  and  in  the  early  stages  of  many  inflammations, 
alcohol  is  not  required,  but  if  at  any  time  the  pulse  becomes  feeble, 
the  tongue  grows  dry,  or  delirium  supervenes,  stimulants,  such  as 
whisky  or  brandy,  should  be  freely  given.  Elderly  people  and  those 
who  have  been  previously  reduced  by  wasting  diseases  require  earlier 
stimulation  in  the  form  both  of  meat  extracts  or  meat  juice  and  al- 
cohol. From  four  to  six  ounces  or  half  a  pint  of  liquor  may  be  pre- 
scribed in  twenty-four  hours,  according  to  its  effect  on  the  pulse.  In 
the  milder  inflammations,  especially  those  of  tubercular  joints,  malt 
liquors  may  be  of  service. 

A  good  strong  toddy  at  night  may  be  made  to  take  the  place  of 
opium. 

Burns,  when  severe  or  extensive,  require  prompt  and  energetic 
stimulation.  In  bad  cases  a  pint  and  a  half  of  brandy  must  be  given 
in  twenty-four  hours. 

In  chronic  surgical  diseases,  attended  by  the  formation  of  pus, 
fresh  green  vegetables  and  fresh  fruits  are  often  serviceable,  both  for 
their  antiscorbutic  and  laxative  effect.  Lemonade,  oranges,  baked 
apples,  or  stewed  prunes  are  recommended.  Fats  are  also  especially 
needed,  and  butter,  cream,  olive  oil,  or  cod-liver  oil  should  be  added 
liberally  to  the  diet  when  the  patient  is  able  to  digest  foods  of  this 
class. 


PART   IX. 
RATIONS,  DIETARIES. 


ARMY  AND   NAVY  DIETS. 

The  food  furnished  to  soldiers  and  sailors,  both  in  time  of  peace 
and  war,  is  more  accurately  weighed  and  measured,  and  its  effects 
are  more  accurately  studied,  for  economic  reasons  than  is  the  diet  of 
any  other  class  of  men,  even  including  hospital  patients.  While 
seeking  to  furnish  wholesome  variety  it  is  necessary  to  keep  the 
quantity  of  food  as  uniform  as  possible,  and  this  may  be  done  by 
substitution  of  articles  the  nutrient  power  of  which  is  closely  re- 
lated ;  thus  eggs  may  be  occasionally  substituted  for  milk,  or  peas 
or  beans  may  be  served  for  a  change  instead  of  cereals. 

The  United  States  Army  Rations. 

A  "ration"  is  technically  the  total  quantity  of  food  issued  for 
one  man  for  twenty-four  hours  in  accordance  with  law,  and  not, 
as  often  supposed,  the  allowance  for  one  meal.  The  original  prin- 
ciples upon  which  military  rations  have  been  selected  are  thus  sum- 
marised by  Captain  Charles  E.  Woodruff,  Assistant  Surgeon,  U.  S. 
Army.  (Journal  of  the  United  States  Cavalry  Association,  March, 
1894,  p.  74.) 

"  I.  Economy  is  essential. 

"  2.  The  food  must  be  the  product  of  the  country  at  large,  neither 
a  specially  prepared  article  nor  the  output  of  a  few  manufacturers. 

"  3.  The  articles  must  be  easily  preserved  in  all  climates  by  the 
most  ignorant  men. 

**  4,  The  articles  must  be  easily  transported  and  capable  of  the 
roughest  handling  during  transit. 

"  5,  The  ration  is  intended  for  the  strongest  and  most  robust 
men  in  the  nation,  and  it  is  acknowledged  that  the  sickly  would 
be  killed. 

"  6.  It  must  approximate  to  the  food  used  by  the  nation  at  large, 
so  that  there  will  be  no  rapid  change  of  diet  on  enlistment  that  would 
impair  the  health. 

680 


ARMY   AND   NAVY   DIETS. 


68 1 


^    "  For  these  reasons  the  soldier's  ration  has  always  been  simple 
and  dry." 

Some  of  these  principles,  as  the  author  quoted  points  out,  are 
radically  wrong.  It  is  false  economy  to  furnish  too  cheap  or  mo- 
notonous diet,  which  only  courts  disease  and  swells  the  pension  roll. 

After  the  Revolutionary  War,  in  1785,  the  army  ration  consisted 
of  one  pound  of  beef,  one  pound  of  bread,  and  one  gill  of  rum.  This 
was  quite  insufficient,  and  was  subsequently  increased  (Woodruff). 
During  that  war,  in  addition  to  the  above  ration,  the  soldier  received 
one  pint  of  milk,  a  little  molasses,  and  a  few  dried  vegetables,  with  a 
quart  of  beer  in  place  of  rum. 

The  present  United  States  army  ration  costs  less  than  fifteen 
cents.  The  German  soldier  is  expected  to  eke  out  his  peace  ration 
by  supplies  contributed  from  his  home,  and  the  French  and  English 
soldier  by  contributions  from  his  pay,  but  in  the  United  States  the 
men  usually  serve  so  far  from  home  that  this  system  is  neither  eco- 
nomical nor  desirable.  Moreover,  with  the  improvements  in  canning 
and  other  methods  of  food  preservation  and  condensation,  it  is  no 
longer  necessary  for  the  ration  to  be  the  product  of  the  immediate 
country, 

U.  S.  Army  Ration  (Captain  Woodruff,  U.  S.  Array). 


Component. 


Meat. 


Bread . 


Dried  vege- 
tables . . . 


Fresh  vege- 
tables . . . 


Coffee . 

Sugar . 


Condiments 
and  addi- 
tional ar 
tides 


One  article  of  each  list. 


12  oz.  pork 

12  oz.  bacon 

22  oz.  salt  beef 

20  oz.  fresh  beef 

20  oz.  mutton 

14  oz.  dried  fish 

18  oz.  pickled  fish 

18  oz.  fresh  fish 

18  oz.  flour 

18  oz.  soft  bread 

16  oz.  hard  bread 

20  oz.  corn  meal 

2?  oz.  beans  or  peas. 
i|  oz.  rice  or  hominy. 

I  lb.  potatoes  or 

-^Q  potatoes  and  -^  onions  or 
^  potatoes  and  ^  onions  or 
4t5  potatoes  and  t^o  canned  tomatoes, 
■jV   potatoes  and  1^  vegetables,  such  as  cab 
bage,  beets,  carrots,  turnips,  squash,  etc. 

I I  oz.  green  coffee. 
IjV  oz.  roasted  coffee. 
■^  oz.  tea. 

2f  oz.  sugar. 

\^  gill  mo!asses  or  sirup. 

■^  gill  vinegar. 

\^  oz.  salt. 

iSf  oz.  pepper. 

^  oz.  candles.     [In  the  field.] 

\%  oz.  soap. 


In  10  days  it  is  usual 
to  give  7  days'  ration  of 
fresh  beef,  2  of  bacon, 
and  I  of  salt  pork.  The 
other  articles  are  very 
seldom  issued. 

Soft  bread  is  the  in- 
variable issue  in  garri- 
son. 


68^ 


RATIONS,   DIETARIES. 


It  is  poot  economy  to  make  the  change  too  radical  between  the 
garrison  and  field  ration,  for  in  the  latter  service  men  are  exposed  to 
conditions  of  hardship  and  fatigue  which  demand  a  more  nutritious 
and  varied  diet  than  they  obtain  in  barracks.  As  shown  by  Wood- 
ruff, the  history  of  all  prolonged  wars  presents  a  far  greater  death 
rate  from  disease  than  from  the  wounds  of  battle,  and  much  of  the 
former  is  caused  by  improper  or  insufficient  food.  The  active  soldier 
should  have  meat  three  times  a  day  (Woodruff). 

When  leading  a  comparatively  inactive  post  life  the  foregoing 
ration  may  prove  too  large — i.  e.,  the  food  furnishes  more  energy 
than  the  body  needs,  but  there  is  not  always  enough  variety.  Any 
excess  of  food  is  then  sold  to  a  co-operative  store,  and  the  money  thus 
acquired  is  expended  in  securing  a  few  luxuries  to  give  the  needed 
variety  to  stimulate  the  appetite. 

U.  S.  Army  Ration  in  the  Field  (Woodruff). 


Meat.. 
Bread . 


Vegetables 

Fresh  vegetables. 

Coffee 

Sugar 


(  12  oz.  fat  pork  or 
\  12  oz.  fat  bacon, 
j  i8.  oz.  flour  or 
\  i6  oz.  hard  bread. 

{2f  OZ.  beans  or 
2f  oz.  peas  or 
if  oz.  rice  or 
if  oz.  hominy. 

i6  oz.  potatoes  (if  they  can  be  carried). 
(  if  oz.  green  cofifee  or 
\  1^5-  oz.  roasted  coffee  or 
(  /,-  oz.  tea. 
1^  oz.  brown  sugar. 


~  (  Maximum. 

Grammes.  ■{  n/r-   • 

I  Minimum.. 


Average . 


Protein. 

Fats. 

Carbo- 
hydrates. 

106 
64 

320 
240 

540 
460 

85 

280 

500 

Calories. 

5,166 
4.722 

4.944 


The  most  concentrated  ration  which  it  is  practical  for  soldiers  to 
carry  in  the  field  consists  of  bacon,  hard-tack,  and  coffee.  This  is  a 
scorbutic  diet,  and  it  always  produces  constipation,  which  may  cause 
considerable  suffering.  To  obviate  this  it  is  now  customary  to  carry 
desiccated  fruits,  which  are  concentrated  by  drying,  and  which  are  not 
spoiled  by  extremes  of  temperature  (Woodruff). 


U.   S.   ARMY   TRAVEL  FATION    (Woodruff). 

"  When  cooking  is  impracticable  on  account  of  travelling  by  cars 
or  rapid  marches,  or  for  other  reasons,  a  special  cooked  ration  is 
issued.     The  items  of  this  ration  are  stated  below. 


ARMY   AND   NAVY   DIETS. 
"  Travel  Ration. 


683 


Meat 

Bread | 

Vegetables 

Coffee 


12  oz.  canned  beef,  fresh  or  corned. 

18  oz.  soft  bread  or  i  t  ..  1        •  u*   »  *    «i  lu 

16  oz.  hard  bread j- Total  weight,  2  to  2i  lbs. 

g^  to  ^  lb.  baked  beans,  J 

21  cents  a  day  for  the  purchase  of  liquid  coffee  en  route. 


"  The  above  has  the  followin 

g  composition  (approximately)  : 

Protein. 

i?-,c         1      Carbo- 
^^^^-           hydrates. 

Calories. 

150 
120 

170                417 
oj.        1        iSn 

3.900 
2,900 

Orammes.  \  Ar:„:„„„ 

135 

132 

400 

3.400 

"  This  ration  is  insufficient  for  active  men,  being  equivalent  to  the 
food  of  men  of  sedentary  habits.  The  protein  is  the  only  ingredient  in 
nearly  the  proper  amount,  and  this  arises  from  the  meats  and  beans." 

Uncooked  Food  of  Garrison  Ration  for  Ten  Days.     Weights  in  Pounds. 
Daily  Average,  4404  Men  (Woodruff). 


Bacon 

Beans 

Pork 

Sugar,  brown . .  . 

Flour 

Beef 

Potatoes 

Onions 

Oatmeal 

Com  meal 

Apples,  canned  . 
Apples,  dried  . . . 
Tapioca  (26)  and 

cornstarch  (13) 

Butter 

Sirup 

Lard 

Rice 

Com,  canned... 
Tomatoes,  can'd. 
Macaroni        (51) 

and   vermicelli 

(li) 

Milk,  fresh,  lbs.. 
Milk,  condensed, 

lbs 

Cheese 

Prunes 

Cabbage        and 

sauerkraut .... 

Ham 

Apricots 

Barley 

Peas    

Raisins 

Chocolate 

Totals 


Gross 
weight. 


Waste 


27:^1 
42a 
34-1 
731 
4.379 
5,025 
5,  "6 
700 
44 
85 
10 
183 

39 
58 
16s 
io7i 
26 
63 
332 


5=* 
31 

31  I 

10* 

35 

250 
33 
20 

5  ! 

14  I 
3 


3* 
31 


I26i 

1. 131 

1,386 
150 


Net 
weight. 


270 
42?* 
312* 
731 
■4,252* 
3.894 
3.730 
550 
44 
85 
10 
183 

39 
58 
165 
107* 
26 
63 
332 


52* 
31 

31 
10 

15 

200 
28 


Water. 


54.00 

54-05 

37.85 

21.93 

531.56 

!,i96.70 

■,943.00 

481.80 

3-34 

12.75 

8.32 

46.85 

0.78 

6.09 

70.60 

12.90 

3.22 

51.22 

318.72 


6.88 
25.61 

7.75 
350 
10.00 

182.00 
11.63 
13-50 


0.55 
6.45 
0.48 


Protein. 


21.60 

99.10 

2.82 


467.78 
682.97 
78-33 
7-70 
6.65 
7.82 
0.02 
1.65 


0.58 


0.65 
1.92 
1.77 
2.66 


4-73 
1.58 

5-27 
3-30 
0-75 

4.30 
4.68 
0.40 
0.65 
1.20 
0.05 
0.60 


18,598  ,2,9oei  15,689*7.120.501,413.21 1,657.175,343.65154.8219,446,960 


Fats. 


187.65 

8.57 
259.00 


46.78 
978.38 
3-73 
1.65 
3-13 
3-23 
0.04 

3. 


Carbo- 
hydrates, 


353.80 


49-30 


89.66 
0.14 
0.70 
1.33 


0.15 
1.50 


3.41 
2.20 


0.60 
11.00 


0.14 
0.08 


1.50 


705-42 
3,185.12 


667.67 

55.55 
30.01 
60.01 

1-59 
130.85 

38.14 

0.29 

90.60 


20.65 
8.32 
8.30 


40.32 
2.00 

13-64 
0.50 
4.00 

11.00 


6.00 
3-8o 
2  54 
3.5c 
0.30 


Salts. 


6.75 
13.29 

13  14 

3-66 

21.26 

35-95 

37  30 

3-30 

0.88 

1.19 

0.03 

2.57 

0.08 

1.74 
3.80 
4.30 
0.14 
0.38 


0.42 
0.31 

0.93 
0.50 
0.25 

2.30 

0.76 
0.12 
0.15 
0.12 
0.08 


Calories. 


831,600 
691,228 

1,097,753 
1,312,081 
6,991,110 
5,409,392 
1,398.750 

123,750 
81,400 

139.825 
3,150 

259,494 

70,980 
209,670 
168,795 

383.775 
42,380 
21,735 
26,560 


73.81S 
12,552 

49.442 
16,000 
3,500 

31,000 

54,880 

9,2CO 

9,000 

7,043 
6,153 
7,950 


684 


RATIONS,   DIETARIES. 


-   - 

Pounds 

Grammes. 

Daily    average 

per  man 

4.22 

0.66 

3.56 

733 

145 

17X 

550 

16 

Counting  flour  as 

bread,  amount 

eaten  is  4  lbs. 

per  man.     Per 

cent  of  amount 

4; 

c 

II 

34 

1 

4,416 


The  usual  army-ration  tables  are  misleading  in  that  they  omit  to 
account  for  the  consumption  of  considerable  accessory  food,  which 
is  purchased  by  the  soldier  in  addition  to  the  portion  he  receives  as 
fixed  by  law.  Captain  Woodruff  has  taken  pains  to  carefully  com- 
pute the  nutrient  value  of  the  entire  food  eaten  by  the  men  of  his 
garrison  at  Fort  Assinniboine,  Montana,  during  a  period  of  ten  days. 
His  table,  taken  from  the  Journal  of  the  American  Medical  Associa- 
tion, December  3,  1892,  p.  651,  is  above. 

Additional  Articles  consumed. 


338  lb.  green  coffee 

8  lb.  tea 

20  gall,  vinegar \ 

128  1b.  salt ) 

10  lb.  pepper 

11  bottles  flavouring  ext'ts. 

3  lb.  mustard. 

24  lb.  baking  powder. 
6  lb.  currants. 
5  gall,  pickles. 

4  kegs  pickled  pigs'  feet  . . 


Daily  per 
man. 


1 .  23  OZ. 
0.03  OZ. 

0.14  gill 

0.46  OZ. 
0.036  OZ. 


Allowance. 


1 .  60  OZ.  or 

0.32  OZ. 

0.32  gill 

0.64  OZ. 
0.04  OZ. 


r  Allowance  is  large,  to  allow  of 
J  making  a  saving  to  be  used 
I  in  making  sauerkraut  and 
[     pickles  in  the  fall. 


Though  containing  much  energy,  it  is  omitted  because 
composition  is  unknown,  and  the  actual  amount  per 
man  is  very  small. 


Foreign  Army  Rations. 

Soldiers'  Daily  Peace  Ration,  in  Ounces  Avoirdupois. 


British 
(average). 

French. 

Austrian. 

German. 

Bread 

24.0 
12.0 

35-2 
10.6 

3I-0 

9.87 

26.50 

(8.81  (larger  ration) 

(  3 .  80  (smaller  ration) 

Meat  (uncooked) 

It  is  apparent  from  this  table  that  the  French,  Austrian,  and  Ger- 
man rations  all  contain  more  bread  and  less  meat  than  the  English. 
In  addition,  the  men  have  potatoes  and  other  vegetables,  green  or 


ARMY  AND   NAVY   DIETS.  685 

dried,  besides  sugar,  coffee,  salt,  etc.,  which  are  either  issued  with 
the  ration  or  purchased  with  a  special  allowance  of  pay,  so  that  the 
above  figures,  which  apply  to  only  two  articles,  fall  somewhat  short 
of  the  actual  food  consumed.  For  example  :  The  British  soldier  re- 
ceives a  total  of  sixty-five  ounces  of  solid  food  against  the  French 
soldier's  fifty-one  ounces  (Parkes) ;  but  many  of  them  are  under- 
grown  men,  being  several  years  under  twenty-five,  up  to  which  period 
the  formation  of  the  bones  is  not  always  complete. 

In  England  the  daily  ration  of  the  soldier  on  home  service  con- 
sists of  one  pound  of  bread  (twenty-four  ounces  is  given  above  as 
the  average  for  foreign  service)  and  three  quarters  of  a  pound  of 
meat,  which  is  supplemented  by  an  allowance  of  about  fivepence  a 
day  to  be  expended  on  minor  articles  of  diet,  green  vegetables,  milk, 
sugar,  and  beverages. 

Colonel  WoodhuU  states  that  "  in  active  field  service  the  whole 
ration  is  supplied  outright  by  the  Government.  It  varies  with  the 
climate  and  the  campaign,  but  the  standard  schedule  is  as  follows: 
Meat,  fresh,  salt,  or  preserved,  one  pound.  Bread,  one  and  a  quarter 
pound,  or  biscuit  [hard  bread],  one  pound,  or  flour,  one  pound;  tea, 
one  sixth  of  an  ounce;  coffee,  one  third  of  an  ounce;  sugar,  two 
ounces;  salt,  half  an  ounce;  pepper,  one  thirty-sixth  of  an  ounce; 
fresh  vegetables,  when  procurable,  half  a  pound,  or  compressed  vege- 
tables, one  ounce.  Also,  'when  ordered  by  the  commanding  gen- 
eral on  the  recommendation  of  the  medical  officer,  lime  juice,  half 
an  ounce  ;  sugar,  a  quarter  of  an  ounce ;  rum,  two  and  a  half  ounces." 

In  the  French  army  legumes  form  an  important  element  of  the 
ration,  to  some  extent  replacing  animal  food,  and  many  experi- 
ments have  been  made  with  the  German  army  in  regard  to  the 
introduction  of  vegetable  food,  especially  pea  meal,  which  is  rich  in 
nitrogenous  material. 

In  France  and  Holland  during  active  service  in  the  field,  in 
manoeuvres,  or  in  battle  the  diet  is  materially  increased. 

The  larger  ration  of  the  German  army,  issued  during  the  marches 
or  manoeuvres,  contains  about  five  ounces  more  meat  and  several 
ounces  more  vegetable  food,  and  in  war  thirteen  ounces  of  meat 
are  given.     Bacon,  salt  meat,  and  rice  are  also  supplied. 

Parkes  gives  the  following  detailed  table  for  a  liberal  war 
ration : 

Bread li  pound. 

Fresh  meat,  without  bone i 

Peas  or  beans 3  ounces. 

Potatoes  and  green  vegetables i  pound. 

Cheese 2  ounces. 

Sugar * 2 

Salt i  ounce. 

Pepper I'ir 


686 


RATIONS,   DIETARIES. 


Ground  coffee I  ounce. 

Tea i     " 

Red  wine lo  ounces. 

Or  beer 20       " 

All  the  chief  armies  of  Continental  Europe  issue  a  wine  ration  m 
war  times.  To  the  French  war  ration  are  added  nine  ounces  of  wine 
or  two  and  a  quarter  ounces  of  brandy /^r  diem. 

Navy  Rations. 

From  Table  A,  showing  the  Different  U.  S.  Navy  Rations  and  their  Compo- 
nent Parts,  as  established  by  Law,  with  the  Substitutes  legally  allowed  for 

each  Article. 

Allowance  for  General  Use. 


Rations  as  composed 
BY  Law. 

EITHER   OF  THE    FOLLOWING 

Specified  by  law. 

Substitutes  authorised  by  law. 

Ration  No.  i 

I  lb.  salt  pork. 

\  pt.  beans  or  peas. 

\\  lb.  fresh  meat,  or 
f  lb.  preserved  meat. 
Vegetables  of  equal  value,  or 
\  lb.  rice. 

Ration  No.  2 

Ration  No.  3 

1  lb.  salt  beef. 
\  lb.  flour. 

2  oz.  dried  fruit. 

f  lb.  preserved  meat. 
\  lb.  rice. 
2  oz.  butter. 

I  oz.  desiccated  mixed   vege- 
tables. 

\\  lb.  fresh  meat,  or 

f  lb.  preserved  meat. 

Vegetables  of  equal  value. 

No  substitute. 

\  pt.  beans  or  peas. 

No  substitute. 

6  oz.  canned  vegetables. 

Ration  No.  4 

1  lb.  preserved  meat. 

2  oz.  butter. 

6  oz.  desiccated  tomatoes. 

No  substitute. 
No  substitute. 
6  oz.  canned  tomatoes. 

Weekly  Allowance. 


\  pt.  pickles. 
\  pt.  molasses. 
■J  pt.  vinegar. 


Daily  Allowance. 

14  oz.  biscuit. 

I  lb.  soft  bread. 
I  lb.  flour. 
\  lb.  rice. 

\  oz.  tea. 

2  oz.  coffee. 
2  oz.  cocoa. 

4  oz.  sugar. 

For  coffee  and  sugar,  extract 
of  coffee  combined  with  milk 
and  sugar  may  be  substitut- 
ed by  the  Secretary  of  the 
Navy,  if  not  more  expensive. 

The  law  allows  one  of  the  above  complete  rations  to  be  used  on 
any  or  each  day  of  the  week,  or  they  may  each  be  used  in  turn  as 
convenient,  in  case  it  becomes  necessary  to  vary  the  order  prescribed 
elsewhere.     Estimated  average  cosX.  per  capita  per  diem^  thirty  cents. 


ARMY   AND   NAVY   DIETS. 


687 


From  Table  C,  showing  the  Different  Articles  of  the  U.  S.  Navy  Ration,  for 
which  Practical  Equivalents  or  Substitutes  are  permitted,  with  the  Quan- 
tity of  each  allowed  for  Issue. 


Articles  named  in 
THE  Law. 


Articles  considered  as  included  under  names  given  in 
preceding  column. 


Bread . 


Flour . 


Preserved  meat. 


Dried  fruit 


Tea.. 
Cocoa. 


j  Biscuit 

]  Soft  bread 

Corn  meal 

Corn  (hominy) 

Oatmeal 

Rye 

Wheat 

'  Roast  beef 

Canned  mutton 

Chicago  corned  beef. 

Brawn 

Ham 

Bacon 

Sausage 

i  Dried 

Fish  \  Smoked 

(  Pickled 

'  Dried  apples.  ~ 
Peaches. 
Raisins. 
Currants. 
Prunes. 
Figs. 
Dates. 

-  May  be  substituted  for  each  other. 


Quantity  allowed  per 
ration. 


14  OZ. 

I  lb. 


As  substitute  for 
I  lb.  bread. 


}-0r  any  other  kind  of  dried  fruit 


Fresh  meat . 


Vegetables 


-  Or  any  other  kind  of  fresh  meat  . 


Beef. 

Mutton. 
\  Veal. 

Pork. 

Poultry. , 

Fresh  (such  as  can  be  procured). 
'  Canned  (assorted  kinds) 


i^  OZ. 

2  OZ. 


lilb. 


lilb. 
6  OZ. 


From  Table  F,  showing  the  Quantities  of  the  Different  Articles  of  the  U.  S. 
Navy  Ration  which  are  required  for  One  Man  for  One  Year. 

Biscuit 319I  pounds. 

Biscuit  (with  flour) 182 

Com  meal 5* 

Oatmeal 52 

Rye  flour  or  hominy 52 

Wheat  flour 52 

Salt  pork 104 

Beans 6^  gallons. 

Peas 3i 

Salt  beef. 52    pounds. 

Rice 26 

Dried  fruit I3 

Butter igi 

Tomatoes ^9» 

Canned  meal 78 

46 


688  RATIONS,   DIETARIES. 

Hatn  or  bacon 39  pounds. 

Sausage  or  salt  fish 39  " 

Coffee 26  " 


Tea 4» 

Cocoa 19^        " 

Sugar 9ii        " 

Pickles 26         " 

Molasses 3i  gallons. 

Vinegar 3i       " 

Canned  vegetables 39    pounds. 

The  British  Navy  ration  contains  one  pound  of  fresh  meat,  one 
pound  and  a  half  of  bread,  or  one  pound  and  a  quarter  of  sea 
biscuit. 

DIET  IN    PRISONS. 

In  prisons,  penitentiaries,  or  reformatories  the  diet  should  be 
adapted  to  keep  the  patients  in  good  health  through  periods  of 
years,  while  it  is  maintained  at  a  minimum  of  expense  to  the  com- 
munity. A  brief  review  of  such  established  diets  is  useful  in  furnish- 
ing an  idea  of  quantity  and  quality  of  food  required  to  fulfil  the 
necessary  conditions. 

Voit  calculated  that  for  a  prisoner  not  engaged  in  hard  labour 
the  following  diet  is  sufficient  to  maintain  health  :  Carbohydrates, 
three  hundred  grammes;  albumin,  eighty-five  grammes;  fat,  thirty 
grammes,  or  a  proportion  of  about  10,  3.5,  and  i. 

In  some  penal  institutions  the  inmates  are  placed  upon  a  pro- 
gressive diet — that  is,  a  diet  which  is  regulated  according  to  the 
duration  of  their  sentence,  the  degree  of  labour  exacted  from  them, 
and  their  conduct.  Such  a  diet  has  been  recommended  by  the 
British  Commissioners  of  Prisons,  graded  for:  (i)  Periods  of  seven 
days  or  less.  (2)  Periods  between  seven  days  and  one  month.  (3) 
Periods  between  one  and  four  months.  (4)  Periods  exceeding  four 
months. 

A  somewhat  similar  system  is  detailed  below — that  of  the  United 
States  Army  Prison  at  Fort  Leavenworth. 

Diets  of  the  United   States   Army   Prison,  Fort 
Leavenworth,  Kansas. 

general  diet. 

Breakfast. — Hash,  on  Tuesday,  Wednesday,  Thursday,  Saturday 
and  Sunday.  Mutton  or  beef  stew,  on  Monday  and  Friday.  Coffee, 
one  quart  each  morning. 

Dinner. — Pork,  one  day  each  week.  Corned  beef,  one  day  each 
week.  Roast  beef  and  gravy,  three  days  each  week.  Boiled  beef 
and  gravy,  two  days  each  week.    Vegetable  soup,  daily  except  Sunday, 


DIET   IN   PRISONS. 


689 


One  pint  of  coffee  each  Sunday.  Pork  may  be  substituted  for 
corned  beef  or  boiled  beef  one  day  each  week  during  cold  weather. 

To  the  above  will  be  added  pickled  cucumbers,  beets,  or  toma- 
toes on  alternate  days,  and  such  other  vegetables  as  may  be  avail- 
able from  the  prison  farm. 

Supper. — Tea  or  coffee,  one  quart ;  bread,  as  much  as  required. 
Stewed  apples  or  prunes  on  alternate  days. 

No.  I.  The  following  diet,  known  as  "  Solitary,"  is  given  prison- 
ers confined  in  cells  for  punishment,  while  not  performing  any 
labour : 

Breakfast. — Bread,  eight  ounces;  water  ad  libitum. 

Dinner. — Bread,  eight  ounces;  water  ad  libitum. 

This  punishment  is  given  only  for  short  periods,  varying  up  to 
twenty  days. 

Total  farinaceous  foods,  sixteen  ounces. 

No.  2.  The  following  diet,  known  as  "Restricted,"  is  given 
prisoners  confined  in  cells  for  punishment,  while  not  performing 
any  labour : 

Breakfast. — Hash  or  stew,  eight  ounces.  Bread,  seven  and  a  half 
ounces. 

Dinner. — Soup,  eight  ounces.  Bread,  seven  and  a  half  ounces. 
Salt  ad  libitum. 

Supper. — Bread,  eight  ounces. 

The  eight  ounces  of  bread  for  supper  to  be  given  after  the 
twenty  days  of  subsistence  on  the  previous  diet. 

Total  proteid  food,  eight  ounces ;  total  farinaceous  food,  twenty- 
three  ounces. 

No.  3.  The  following  diet  is  given  to  prisoners  who  have  under- 
gone punishment : 

Breakfast. — Hash  or  stew,  ten  ounces.  Bread,  ten  ounces. 
Coffee  and  sugar  in  the  usual  amounts. 

Dinner. — Soup,  the  usual  amount.  Beef,  eight  ounces,  or  pork, 
six  ounces.  Peas  or  beans,  six  ounces,  or  hominy  in  the  usual 
amount,  or  potatoes,  eight  ounces.  No  other  vegetables  except 
such  as  are  contained  in  the  soup. 

Supper. — Bread,  ten  ounces.  Tea  and  sugar  in  the  usual 
amounts. 

To  prisoners  who  have  been  on  "  Restricted  Diet  "  for  more 
than  ten  days  and  less  than  twenty  days,  or  on  "Solitary  Diet" 
for  ten  days,  the  above  diet  (No.  3)  is  given  for  two  days. 

For  those  who  have  been  on  "  Restricted  Diet  "  for  twenty  days 
or  more,  or  on  '*  Solitary  Diet  "  for  fifteen  days,  the  above  diet  (No. 
3)  is  given  for  three  days. 

Following  is  the  dietary  of  the  New  York  State  Reformatory, 
copied  from  the  annual  report  of  that  institution  for  1893. 


690 


RATIONS,   DIETARIES. 


Q 

1.3  § 

i 

U 

1              oo  CO     '^  IT) 
in  Q    CO  0 
COOCO    <N 

0    I-~  0                    N 

TT  tH  CO                          0 

CO   M* 

CO   0  M  'too  r^ 

to  CO 

CO  CO 

to  to 

N 

82 

z 
u 

K 

Z 

Min. 
mat'r 

■«. 

1                       CO    t^CO 

1          6  6  6 

0  a>           00 

H  d            d 

vO    0  0    0    "t 

d  N  CO  c)  d 

ll 

0 

0     CO  M                         W 

O^  P-l 

00  t^  r<  t->  0>  0 

t^   M     0     W     CO    0 

CO  0  0    0    w  CO 

M 

p<  0 

CO   M 

M 

0 

in 
«n 

VI 

0    m  M                         0 

vO  >r)  0              0 

Tt  in  M 

vO     M     Tj-  0     •*  0 

moo  r^  r^  0  CO 

r^O  mo  r^o 

1 

N 

0 

CO  M  H                0 

d  CO  d            d 

in  c^  N  M  M     •          r^  m 

0     0     C^     0     0        •                 0     M 

d  0  d  d  0    •       >n  PI 

M 
0 

•w. 

0  r^  M  m 

00   w   c<-)0 

0  a^t\            N 

j^  M  d            d 

M   M   M  m  't    • 

M     I^   0     N     0        • 

1 

0 

•H  ■<j-  N  d 

N   inoo                  a^ 

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d  4  M            d 

in  't  "t  CO  CO    • 

m  0  •*  0   t-i     • 

6  6  <^  6  6   '• 

0  0 

CO    M 

0 
M 

■«. 

0  CO   w  00 

0    C^co                  0 

M  00    M                        94 

w  M  N  m  Tt    • 

HI  in  CO  0  t^    • 

M     M     W     M 

^'S 

•w. 

0  0  0^  m 

vO    >+  't 

■    »^  0            0 

M  00                     w 

COO                    CO 

0  r~  r^  0  ■<*• 
■<i-  r-  COCO  M 

M      l-H      M 

•««. 

1^  0    ■* 

0                     0 

d            d 

^ 



« 

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a 

K 

<: 

Q 

z 

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u  0 

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vO    N  CO    H 
CO 

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DIET   IN   PRISONS. 


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RATIONS,   DIETARIES. 


From  the  New  York  State  Reformatory  Annual  Report  for  iSgj. 
Calculations  based  on  Prof.  Atwater's  tables,  with  Reformatory  standard  diet  added. 
COMPARISON  OF  DAILY  DIETARIES 


Carbohydrates 


Fats 


m 


Protein         Potential  energy 


Nutrients,  Grammes- 


200  400  600  800  1000  1200 
—I i 1 1 1 1— 


Potential  Energy,  Calories, 


1000  2000  3000  4000  5000  6000  7000  8000 


Subsistence  diet  (Playfair) 

Under-fed  labourers,  Lombardy,  Italy 

Students,  Japan 

Lawyers,  Munich,  Germany 

Well-paid  mechanic,  Munich,  Germany 

Well-fed  blacksmith,  England 

German  soldiers,  peace  footing 

German  soldiers,  war  footing 

French-Canadian  families,  Canada 

Mechanics  and  factory  operatives,  Massachusetts . 

Well-to-do  family,  Connecticut 

College  students.  Northern  and  Eastern  States . 

Machinists,  Boston,  Mass 

Hard-worked  teamsters,  etc.,  Boston,  Mass. 

U.  S.  Army  ration 

U.  S.  Navy  ration 

N.  Y.  State  Reformatory  standard 

Reformatory  standard  daily  ration  * 

Actual  upper  first  grade  dietary 

Actual  lower  first  grade  dietary ... 

Actual  second  grade  dietary 


Playf air's  standard  for  adults,  moderate  exercise. 
Voit's  standard  for  labouring  men  at  moderate  work. 

Voit's  standard  for  prisoners  in  idleness 

Voit's  standard  for  prisoners  at  work 


DIET   IN    PRISONS. 


693 


Exact  figures  corresponding  to  these  lines  are  presented  here- 
with : 


NUTRIENTS,    IN   GRAMMES. 


Reformatory  standard  dietary  daily  ration  * 

Actual  upper  first  grade  ration 

Actual  lower  first  grade  ration 

Actual  second  grade  ration 

Playfair's  standard  for  adults,  moderate  exercise. . . . 
Voit's  standard  for  labouring  men  at  moderate  work 

Voit's  standard  for  prisoners  in  idleness 

Voit's  standard  for  prisoners  at  work 


Protein. 


119 
167 
154 
154 

119 

118 

85 

105 


Fats. 


61 

75 
69 
69 

51 
56 
30 
40 


Carbo- 
hydrates. 


556 
810 

794 
776 

531 
500 
300 
500 


Potential 

energy, 

in  calories. 


3.334 
4,696 

4,524 
4.452 

3.140 
3.050 

1.857 
2,852 


At  a  Conference  of  the  Prison  Association  of  New  York,  held 
in  1893,  the  following  bill  of  fare  was  recommended  for  general 
adoption  in  prisons.  The  quantity  of  food  is  not  specified  (Forty- 
ninth  Annual  Report  of  the  Prison  Association  of  New  York,  for 
the  year  1893,  pp.  90-91)  : 

SUNDAY. 

Breakfast. — Pea  soup,  bread  and  butter. 
Dinner. — Baked  beans,  brown  bread,  pudding. 
Supper. — Bread  or  crackers,  cheese,  milk. 

MONDAY. 
Breakfast. — Oatmeal  or  boiled  rice,  with  sugar  and  milk. 
Dinner. — Salt  fish,  vegetables,  fruit. 
Supper. — Bread  and  butter,  milk. 

TUESDAY. 

Breakfast. — Bean  porridge,  bread. 

Dinner. — Roast  beef,  two  or  more  kinds  of  vegetables,  bread. 

Supper. — Bread  and  milk,  molasses. 


WEDNESDAY. 

Breakfast. — Pea  soup,  bread. 
Dinner.— Beti  or  mutton   stew,  with   vegetables, 
used  in  place  of  potatoes.) 

Supper. — Corn-meal  mush,  molasses. 


(Rice   may  be 


*  All  food  supplies  are  issued  according  to  this  standard  dietary,  except  bread, 
which  is  unlimited.  The  average  consumption  of  bread  per  man  is  somewhat  in  ex- 
cess of  one  and  one  half  ration  per  meal,  thus  accounting  for  the  increase  in  value  of 
the  actual  ration  over  that  of  the  standard  dietary,  which  conforms  very  nearly  in  food 
values  to  the  standards  of  Voit  and  Playfair. 


6q4  rations,  dietaries. 

thursday. 

Breakfast. — Bread  and  butter,  milk. 
Dinner. — Baked  beans,  bread,  fruit. 
Supper. — Bread  and  butter,  cereal,  coffee. 

FRIDAY. 

Breakfast. — Pea  soup,  bread. 

Dinner. — Fresh  fish,  vegetables.  (Rice  may  be  used  in  place  of 
potatoes.) 

Supper. — Bread  and  milk,  cheese. 

SATURDAY. 

Breakfast. — Oatmeal  mush,  milk,  bread. 
Dinner. — Corned  beef,  vegetables. 
Supper. — Bread  and  milk,  molasses. 

THE  MILK  CURE. 

An  exclusive  diet  of  milk  as  a  cure  for  certain  chronic  diseases  is 
advocated  by  some  physicians,  and  in  whose  hands  it  has  met  with 
considerable  success.  Karell,  of  St.  Petersburg,  and  Weir  Mitchell 
are  to  be  mentioned  among  those  who  have  extensively  used  this 
form  of  treatment.  The  treatment  as  a  "  cure  "  does  not  apply  to 
the  temporary  exclusive  milk  diet  of  typhoid  fever  and  similar  acute 
febrile  conditions,  but  it  is  believed  by  the  advocates  of  the  milk 
diet  that  this  form  of  food  not  only  counteracts  certain  abnormal 
conditions  and  meets  definite  requirements  of  the  body,  but  that  the 
milk  diet  itself  possesses  a  special  curative  value  in  some  cases. 
Bauer  says  emphatically,  "  It  is  an  indisputable  fact  that  in  certain 
diseases  a  methodical  use  of  the  milk  cure  gives  results  such  as  can 
be  attained  by  no  other  treatment." 

It  is  recommended  in  obstinate  cases  of  chronic  intestinal  disorders, 
especially  neuralgia,  intestinal  dyspepsia,  and  colitis;  in  chronic  con- 
gestion, hypertrophy,  and  fatty  degeneration  of  the  liver;  in  asthma, 
pulmonary  catarrh,  and  emphysema;  in  dropsies  of  renal,  cardiac, 
and  hepatic  origin  ;  in  hysteria  and  hypochondriasis,  in  which  the 
predominant  symptoms  are  dyspepsia  and  malnutrition ;  and  in 
chronic  catarrhal  conditions  of  the  whole  alimentary  canal. 

The  milk  cure  is  also  recommended  in  cases  of  neurasthenia, 
obesity,  rheumatism,  gout,  chronic  valvular  cardiac  diseases,  chronic 
Bright's  disease,  and  endarteritis.  Lebert  had  good  results  from  it 
in  the  treatment  of  gastric  ulcer.  Weir  Mitchell  observes :  "  The 
study  of  the  therapeutic  influence  and  full  results  of  the  exclusive 
milk  diet  is  yet  to  be  made.     Nor  can  I  but  believe  that  accurate 


THE    MILK   CURE.  6gg 

dietaries  will  come  to  be  a  far  more  useful  part  of  our  means  of 
managing  certain  cases  than  as  yet  seems  possible  (Fat  and  Blood, 
fifth  edition,  1888). 

Dosage  and  Method  of  giving  the  Milk.— The  milk  used  is 
skimmed,  and  it  is  important  to  have  it  obtained  as  fresh  from  the  coun- 
try as  possible.  It  is  customary  to  begm  with  comparatively  small 
doses— about  four  ounces,  once  in  two  hours  throughout  the  day,  with 
one  or  two  doses  at  night.  Karell  gives  the  milk  lukewarm.  At  the 
end  of  a  few  days  the  dosage  may  be  increased  to  six  or  eight  ounces, 
and  the  intervals  made  three-hourly,  and  finally  four-hourly,  when 
twelve  tumblerfuls  are  given  daily.  Pecholier  gave  three  litres /<?r 
dievi,  in  two-hourly  doses.  When  the  treatment  is  undertaken  it 
must  be  carried  out  with  absolute  regularity  and  system,  both  as 
regards  the  quantity  of  milk  consumed  and  the  intervals  at  which  it 
is  given;  otherwise,  if  too  large  an  amount  is  drunk  at  one  time,  or 
the  intervals  are  too  frequent,  undigested  milk  remains  in  the  stomach 
to  mingle  with  the  fresh  doses,  and  abnormal  fermentation  and  dys- 
peptic symptoms  result.  It  is  much  better  that  the  milk  should  be 
given  alone  whenever  large  quantities  are  to  be  taken  for  a  long 
time.  If  diarrhoea  exists,  the  milk  may  be  boiled  or  taken  hot  at 
any  time,  if  the  patient  so  prefers  it,  but  this  is  not  necessary.  If 
the  passages  from  the  bowels  are  normal  in  appearance — small  and 
solid — the  milk  is  being  well  digested  and  absorbed,  and  the  quan- 
tity may  be  increased.  Usually  the  greatest  difficulty  with  indi- 
gestion in  this  form  of  treatment  occurs  during  the  first  week ;  after-, 
ward,  as  a  rule,  the  alimentary  canal  becomes  accustomed  to  the  diet 
and  digestion  proceeds  actively  and  nutrition  improves. 

Many  patients — either  from  imagination  or  from  past  experience 
with  milk  drinking — insist  that  they  are  unable  to  take  it  in  any 
form,  but  it  is  rare,  indeed,  to  find  any  one  who  cannot  digest  milk  if 
it  is  made  palatable  and  properly  prepared.  For  this  purpose,  sug- 
gestions will  be  found  under  the  heading  of  the  article  on  the  Adap- 
tation of  Milk  for  the  Sick  (page  62),  to  which  the  reader  is  referred. 
Not  a  few  learn  to  prefer  the  milk  to  more  highly  seasoned  food.  If 
the  patient  chooses — and  it  is  wholly  a  matter  of  taste — the  milk  can 
be  flavoured  with  very  weak  tea,  weak  coffee,  or  caramel,  and  a  pinch 
of  salt  should  be  added  in  most  cases  to  each  tumblerful.  Excep- 
tionally the  flavour  of  a  little  spice  of  some  sort  may  be  preferred. 
Some  patients  do  better  if  the  milk  is  diluted  by  one  third  or  one 
half  with  some  alkaline  table  water,  lime  water,  or  Vichy,  or  it  may 
be  scalded  with  a  little  boiled  water  to  which  five  grains  of  sodium 
bicarbonate  and.  three  or  four  grains  of  common  salt  are  added. 
Milk  from  first-class  thoroughbred  cows,  such  as  Alderneys,  is  often 
too  rich,  and  it  is  undesirable  to  give  any  milk  in  this  cure  which 
contains  much  cream.     Skimming  the  milk  is  therefore  necessary  in 


6q6  rations,  dietaries. 

most  instances,  and  in  some  cases,  even  after  the  milk  is  skimmed, 
it  is  better  digested  if  considerably  diluted. 

In  carrying  out  this  treatment  much  depends  upon  previously 
gaining  the  confidence  of  the  patient  and  having  him  thoroughly 
understand  the  theory  of  the  cure,  so  that  his  willing  co-operation 
may  be  obtained  in  a  method  which  is  monotonous  and  wearisome  at 
best.  By  a  little  tact  and  persuasion  with  care  in  framing  the  origi- 
nal rules  and  supervision  over  their  execution  the  cure  may  often 
be  conducted  with  great  benefit  in  seemingly  difficult  cas^s.  The 
one  object  of  the  treatment  is  to  enable  the  digestive  organs  to  rest 
and  recuperate  when  they  are  in  an  exhausted  or  irritable  condition 
by  giving  only  small  quantities  of  the  simplest  form  of  food  at  first. 
Later,  as  digestion  improves,  larger  amounts  will  be  tolerated  and 
the  strength  and  nutrition  of  the  patient  will  be  promoted  by  in- 
creasing the  dosage  of  milk  to  whatever  maximum  can  be  reached 
without  taxing  the  stomach. 

Symptoms  accompanying  the  Treatment. — The  frequent 
occurrence  of  constipation  is  a  not  unfavourable  indication  that  the 
milk  is  being  well  digested  and  very  completely  absorbed,  leaving 
but  small  residue.  Diarrhoea  or  obstinate  vomiting,  on  the  other 
hand,  indicate  indigestion  or  malnutrition,  and  the  difficulty  should 
be  corrected  by  temporarily  reducing  the  quantity  of  milk  and  pro- 
longing the  intervals  between  the  doses  to  four  or  even  six  hours. 
The  constipation  is  met  by  the  use  of  a  pill  of  two  grains  of  inspis- 
sated oxgall,  or  by  the  compound  licorice  powder  (pulvis  glycyrrhizge 
compositus),  or  a  dose  of  rhubarb,  or  half  an  ounce  of  castor  oil,  or 
thirty  to  sixty  minims  of  fluid  extract  of  cascara.  The  addition  of 
coffee  to  the  milk  drunk  in  the  earlier  hours  of  the  day  sometimes 
renders  it  more  laxative,  and,  if  necessary,  prunes  or  stewed  or  baked 
apples  may  be  taken  once  daily,  in  the  middle  of  the  afternoon. 

In  addition  to  the  milk,  patients  should  be  allowed  a  reasonable 
quantity  of  water  or  of  aerated  waters.  It  is  well  that  some  water 
should  be  given  even  though  thirst  be  not  complained  of.  After  a 
fortnight  or  three  weeks  some  patients  complain  very  much  of  the 
absence  of  solid  food,  ^d  in  such  cases — if  the  digestion  is  favoura- 
ble— stale  bread,  crackers,  dry  toast,  or  a  little  salted  Dutch  herring 
may  be  allowed,  or  a  milk  soup  thickened  with  barley  or  groats. 
Some  patients  do  well  to  take  one  of  the  prepared  starchy  foods,  such 
as  are  in  familiar  use  for  infant  feeding.  As  a  usual  result  of  the 
treatment,  patients  lose  weight  somewhat  during  the  first  ten  days 
or  two  weeks,  but  after  the  quantity  of  milk  begins  to  be  increased 
they  may  gain  considerable  flesh  and  strength,  excepting  in  the  case 
of  very  obese  persons,  who  may  continue  to  lose  fat  after  the  maxi- 
mum dosage  of  milk  has  been  attained.  Drowsiness  is  also  a  com- 
mon symptom  in  the  first  few  days.     The  urine  is  increased,  and  is 


THE   WHEY   CURE.  607 

pale  in  colour  and  of  low  specific  gravity.  The  tongue  is  covered 
with  a  thick  white  or  yellowish  coating,  and  there  is  usually  a  disa- 
greeable, mawkish  taste  in  the  mouth.  The  latter  condition  may  be 
relieved  very  largely  by  proper  care  (compare  Treatment  of  Typhoid 
Fever,  page  398).  The  increased  quantity  of  urine  is  possibly  due 
to  the  large  amount  of  lactose,  which  is  somewhat  diuretic  in  action ; 
but  when  given  alone  I  have  not  found  it  to  possess  exceptional 
power  in  this  direction.  According  to  Weir  Mitchell,  the  uric  acid  is 
greatly  reduced  in  the  urine  and  the  colour  is  of  a  somewhat  greenish 
hue,  and  indol  and  skatol  also  disappear.  Weir  Mitchell  calls  atten- 
tion to  the  extensive  changes  in  assimilation  in  the  body  which  these 
various  alterations  in  excretions  indicate. 

After  about  six  weeks  of  this  milk  diet  the  substitution  of  solid 
food  is  to  be  gradually  made,  reducing  the  number  of  milk  meals  by 
at  first  one  a  day  for  a  day  or  two,  then  by  two,  and  so  on  until  all 
food  is  taken  solid,  and  Karell  suggests  that  lean,  raw  scraped  beef 
with  stale  bread  is  the  best  to  begin  with.  The  diet  should  be  so 
graded  as  to  consist  largely  of  milk  for  several  months. 

THE  WHEY  CURE. 

The  whey  cure  has  been  extensively  practised  in  the  mountainous 
regions  of  Germany  and  Switzerland  and  at  various  springs  or  baths, 
especially  those  of  the  alkaline  waters,  which  latter  are  frequently 
mingled  with  the  whey  and  drunk  either  warm  or  cold.  The  treat- 
ment is  rigorous,  and  consists  in  confining  the  patient's  diet  largely 
to  the  use  of  about  twenty  ounces /^r  diem  of  fresh  milk  whey.  The 
principles  of  the  treatment  are  essentially  similar  to  those  of  the  milk 
cure,  but  in  whey  the  casein  of  the  milk  has  been  artificially  removed 
to  make  cheese  by  the  addition  of  rennet,  the  milk-curdling  ferment. 

Whey  is  made  from  the  milk  of  several  animals,  such  as  the 
sheep,  goat,  mare,  and  ass,  as  well  as  the  cow.  It  consists  of  milk 
sugar,  albumin,  substances  resembling  peptone,  and  a  smaller  quan- 
tity of  fat  with  most  of  the  lactic  acid.  It  is  whitish,  translucent, 
and  opalescent. 

When  milk  has  been  standing  for  some  time  in  the  air  it  becomes 
contaminated  with  bacteria,  which  cause  spontaneous  coagulation, 
and  whey  is  squeezed  out  of  the  contracting  clot ;  but  this  is  sour 
and  not  so  good  as  that  made  by  rennet.  The  percentage  composi- 
tion of  whey  is  as  follows  : 

Water 93-31 

Lactose 4-65 

Fat 0.24 

Proteid 0.82 

Lactic  acid o .  33 

Salt '. 0.65 


6q8  rations,  dietaries. 

The  whey  cure  is  used  for  the  treatment  of  Bright's  disease  and 
chronic  catarrhal  conditions  of  the  aUmentary  canal.  It  is  partic- 
ularly recommended  for  chronic  dyspepsia  and  chronic  irritable 
cough  accompanying  catarrh  of  the  respiratory  mucous  membranes.. 

It  is  said  to  improve  the  secretion  in  chronic  bronchitis,  and  it  in- 
creases the  strength  of  the  pulse,  which  is  attributed  to  its  potassium 
salts  (May).  If  more  than  twenty  ounces  are  ingested  daily  there 
is  an  increased  peristaltic  movement,  with  watery  evacuations,  colic, 
and  dyspepsia. 

Whey,  like  skimmed  milk,  is  diuretic  and  sudorific.  It  therefore 
constitutes  a  useful  beverage  in  fevers.  The  class  of  patients,  many 
of  them  phthisical,  for  whom  the  cure  is  recommended  at  Ems, 
Ischl,  Reichenhall,  etc.,  are  not  fit  subjects  for  a  reducing  diet,  as 
they  have  little  or  no  spare  strength  ;  they  require  rather  abundant 
nourishment,  owing  to  the  catarrhal  processes  which  affect  the 
respiratory  and  alimentary  passages.  However,  in  such  cases  diges- 
tion and  absorption  are  often  greatly  impaired,  and  this  condition  is 
found  to  be  benefited  by  the  use  for  a  short  period  of  the  alkaline 
waters  and  whey.  It  is  not  safe  to  limit  the  diet  exclusively  to 
these  fluids,  and  some  nitrogenous  food  must  be  given,  together 
with  fresh  fruit  and  green  vegetables.  In  Switzerland  and  Germany 
the  whey  cure  is  often  combined  with  the  grape  cure. 

VARIOUS  "CURES." 

There  are  other  diet  systems  or  "  cures,"  which  deserve  passing 
mention  rather  as  matter  of  general  interest  and  as  illustrations  of 
the  effects  of  strong  mental  impressions  or  "mind  cure"  combined 
with  moderation  in  previous  habits  of  overeating  or  gluttony,  than 
because  any  specific  importance  is  to  be  attached  to  the  value  of 
one  such  "cure"  more  than  another. 

Many  diet  "  cures  "  have  been  devised  purely  for  notoriety,  to 
advertise  an  otherwise  unsuccessful  practitioner  or  a  charlatan,  and 
others  again  are  exploited  by  well-meaning  fanatics  who  have 
acquired  a  firm  belief  in  some  dietetic  system  which  has  first  helped 
themselves,  and  which  they  feel  that  they  owe  to  the  world  to  pro- 
mulgate for  the  guidance  of  others.  Neither  are  they  always  fol- 
lowers of  ^sculapius.  Mr.  Banting  (page  603),  whose  name  has 
given  rise  to  a  verb  meaning  to  reduce  corpulency,  was  a  layman, 
and  so  was  Mr.  Graham,  whose  name  is  a  household  adjective  ap- 
plied to  the  flour  which  he  introduced,  and  many  famous  men,  like 
Shelley  and  Goldsmith,  have  sung  the  praises  of  vegetarianism. 

Not  infrequently  an  element  of  religious  fervour  is  added  to  the 
belief  in  the  efficacy  of  some  new  system,  and  long  pilgrimages  are 
made  to  seek  its  chief  apostle.     Such,  for  example,  is  the 


THE   GRAPE   CURE. 


699 


Kneipp  System. — Monseigneur  Kneipp  is  a  Bavarian  priest 
whose  patients  live  cliiefly  upon  a  diet  of  milk,  coarse  bread  of  bran 
and  flour,  soup,  and  cooked  fruits,  with  a  minimum  of  meat,  eggs, 
and  vegetables.  Water  is  principally  drunk,  with  a  little  wine  or 
beer,  but  no  spirits  or  coffee.  This  is  undoubtedly  a  common-sense 
regimen  for  many  persons  who  have  long  abused  their  gastronomic 
powers  by  eating  too  much  and  too  rich  food,  but  he  adds  the  ascetic 
elements  of  wearing  very  light,  loose  apparel  and  walking  about 
barefooted  in  the  grass  before  the  morning  dew  has  vanished.  There 
is  an  institution  for  furnishing  this  unique  and  imaginative  treat- 
ment in  this  country  at  Sharon  Springs,  New  York. 

FRUIT  CURES. 

The  "  fruit  cure  "  has  appeared  in  many  forms.  At  one  time  it 
is  confined  to  oranges,  English  walnuts,  and  cold  water,  and,  strange 
to  say,  some  dyspeptics  are  able  to  digest  it  for  a  little  while;  or  it 
consists  of  sweet  fruits  and  meat  alone — dates,  figs,  prunes,  bananas, 
and  apples — upon  the  theory  that  fruits  were  the  first  food  of  prime- 
val man,  and  ergo  they  are  the  natural  food  of  all  men — an  extreme 
of  atavism,  surely  ! 

There  is  also  a  "  lemon  cure." 

Another  fruit  cure  extends  through  six  weeks.  It  begins  grad- 
ually by  eating  an  apple  or  orange  upon  rising  and  again  upon  retir- 
ing. In  three  or  four  days  the  breakfast  consists  of  several  baked 
apples,  a  small  quantity  of  bread  and  butter,  and  a  little  coffee. 
During  the  forenoon  several  ripe  apples  or  oranges  may  be  eaten. 
At  dinner  fresh  animal  food  is  furnished  with  a  potato  and  roasted 
apples  or  apple  sauce.  Green  vegetables  are  allowed,  but  no  bread 
or  pastry  of  any  kind.  Pickles  may  be  eaten.  During  the  after- 
noon, more  fruit,  oranges,  apples,  grapes.  Supper,  like  breakfast, 
with  a  little  sago  in  milk,  with  currants,  raisins,  or  apples.  This 
diet  is  adapted  to  obstinate  chronic  constipation,  some  cases  of 
obesity,  and  lithaemia. 

THE  GRAPE  CURE. 

The  grape  cure  has  been  advocated  for  many  years  as  beneficial 
in  certain  forms  of  disease,  but,  like  the  majority  of  vaunted  dietetic 
"cures,"  it  is  almost  certain  that  the  chief  benefit  experienced  is 
from  the  change  of  scene  and  the  favourable  climatic  and  hygienic 
surroundings  of  the  patient,  and  possibly  the  influence  of  a  stimu- 
lated imagination.  The  "cure"  is  in  vogue  during  the  grape-bear- 
ing season  of  the  vineyards  in  various  parts  of  southern  Europe, 
especially  at   Meran   and    Montreux.      Grapes,  being   very  largely 


700 


RATIONS,   DIETARIES. 


composed  of  water,  do  not  possess  a  very  high  degree  of  nutritive 
power,  and  it  is  impossible  to  maintain  life  upon  their  exclusive  use; 
but  the  grape  sugar  which  they  contain,  as  well  as  a  large  amount  of 
potassium  and  other  salts,  may  have  some  slight  alterative  effect, 
and  benefit  nutrition.  Grapes  are  also  laxative.  Almost  every  one 
is  fond  of  the  fruit,  and  the  cure  is  therefore  an  agreeable  one  to 
take,  especially  as  the  diet  is  not  too  exclusive,  for  the  eating  of 
large  quantities  of  grapes  is  made  an  adjunct  to  the  employment  of 
highly  nutritious  food. 

Vineyard  labourers  who  eat  little  else  but  grapes  quickly  lose 
weight,  and  other  food  must  be  taken  with  the  grapes  if  the  strength 
is  to  be  maintained,  for  a  pound  of  grapes  contains  a  little  less  than 
three  grammes  of  proteid. 

It  is  recommended  by  Lebert  that  the  grapes  should  be  eaten 
systematically  and  in  quantities  commencing  with  a  half  pound,  and 
seldom  exceeding  four  pounds/^/-  die7n,  although  six  or  eight  pounds 
are  sometimes  eaten.  Owing  to  the  mildly  laxative  effect  of  the 
fruit,  this  cure  is  beneficial  in  cases  of  chronic  constipation,  and 
especially  in  engorgement  and  hypersemia  of  the  liver  accompanied 
by  extensive  venous  congestion,  hemorrhoids,  and  the  formation 
of  various  forms  of  calculi.  In  gastric  catarrh  patients  are  some- 
times allowed  to  eat  six  pounds  of  grapes  a  day.  The  laxative  ef- 
fect is  always  greater  if  the  fruit  is  taken  in  the  intervals  between 
meals,  and  especially  if  taken  fasting  on  rising  in  the  morning.  At 
first  only  half  a  pound  of  grapes  is  to  be  taken  two  or  three  times  a 
day,  from  half  an  hour  to  an  hour  before  meals,  the  quantity  being 
gradually  increased  to  a  pound  or  more  at  each  dose.  Some  pa- 
tients digest  the  grapes  better,  however,  if  they  are  eaten  in  the 
form  of  dessert  than  if  taken  into  an  empty  stomach.  The  laxative 
effect  gradually  increases,  and  is  usually  more  pronounced  after 
several  days. 

When  patients  become  tired  of  the  monotony  of  this  single  fruit 
they  may  be  allowed  to  substitute  pears  or  figs.  It  is  stated  that 
the  gums  may  become  somewhat  swollen  and  tender  from  the  acid 
contained  in  so  much  fruit,  and  to  obviate  this  difficulty  the  mouth 
may  be  cleansed  thoroughly  after  eating  with  listerine  or  a  solution 
of  sodium  bicarbonate,  or  the  mastication  of  a  small  quantity  of 
bread  will  serve  to  cleanse  the  teeth. 

Abundant  other  food  is  allowed  with  the  grapes,  but  it  is 
important  that  it  should  be  of  an  easily  digestible  character,  and 
certain  articles  must  therefore  be  forbidden,  such  as  fats,  rich 
sauces,  gravies,  pickles,  condiments,  the  heavier  vegetables,  such 
as  potatoes  and  the  legumes,  cheese,  pastry,  cakes,  sweets,  and 
beer. 

The  usual  duration  of  the  cure  is  from  a  month  to  six  weeks. 


MEAT   AND   HOT-WATER   CURE.  70I 

The  average  chemical  percentage  composition  of  grapes  is  given  by 
Konig  as : 

Water 78.17 

Sugar 14.36 

Free  acid o. 70 

Nitrogenous  material o. 50 

Extractives i  g5 

Stones  and  woody  fiber 3 .  60 

^^^ 0.53 

The  latter  is  chiefly  composed  of  potash  salts,  some  lime  and 
magnesia. 

Patients  who  have  undertaken  the  grape  cure  without  proper 
supervision  are  very  apt  to  disorder  their  digestion  and  cause  gastric 
catarrh  and  even  jaundice.  Knauthe  says  that  the  eating  of  several 
pounds  of  grapes  daily  may  at  first  cause  symptoms  of  flatulent 
dyspepsia,  more  or  less  vertigo,  and  increased  frequency  of  the 
pulse,  palpitation,  diuresis,  and  malaise.  The  stools  become  more 
frequent  and  semisolid. 

The  grape  cure  is  reputed  to  be  useful  in  chronic  bronchitis,  the 
first  stage  of  phthisis,  emphysema,  in  obesity  when  combined  with  a 
restricted  diet,  in  gastro-intestinal  catarrh,  anaemia,  vesical  catarrh, 
gout,  hepatic  engorgement,  malarial  cachexia,  and  chronic  cutaneous 
affections. 

In  phthisis  the  grapes  should  not  be  given  in  quantities  sufficient 
to  occasion  diarrhoea. 


MEAT  AND   HOT-WATER  CURE. 

The  meat  and  hot-water  cure,  often  called  in  this  country  by  the 
name  of  Salisbury,  one  of  its  chief  advocates,  is  given  to  many 
classes  of  patients — consumptives,  rheumatic  subjects,  and  others. 
Lean  raw  beef  is  ground  to  a  pulp  in  a  machine  which  is  made  for 
the  purpose  and  sold  in  hardware  shops.  It  is  freed  from  all  fibre, 
seasoned  with  salt  and  pepper,  rolled  into  little  balls,  and  cooked 
just  enough  to  turn  the  outside  from  a  red  to  a  drab  colour.  From 
two  to  four  ounces  are  eaten  at  a  meal  at  first ;  later  as  much  as 
seven  ounces  may  be  taken.  In  addition,  from  two  to  four  raw  eggs 
are  given  with  dry  toast.  No  fluid  is  allowed  with  meals,  but  from 
a  half  pint  to  a  pint  of  hot  water  is  given  before  each  meal,  and 
again  at  bedtime. 

This  diet  reduces  corpulency  rapidly,  and  is  beneficial  in  cases  of 
chronic  gastric  catarrh  and  dilatation,  but  it  is  too  rigid  for  many 
patients.  It  is  somewhat  similar  to,  but  much  more  strict  than,  the 
diets  of  Carlsbad  and  Wiesbaden,  which  consist  chiefly  of  lean  meat, 
eggs,  and  milk  with  a  minimum  of  bread,  and  sometimes  fruit. 


702  RATIONS,   DIETARIES. 


THE  DRY  CURE. 


The  "dry  cure  "  is  the  name  given  to  the  treatment  which  con- 
sists in  withholding  fluid  from  the  diet  in  increasing  degree  until  the 
patient  takes  just  as  little  as  is  necessary  to  sustain  life.  If  carried 
to  this  extreme,  however,  thirst  becomes  intolerable,  and  patients 
usually  rebel  against  the  rigour  of  such  treatment. 

Practically  it  is  found  that  the  minimum  of  water  aside  from  that 
contained  in  food  which  patients  can  tolerate  is  about  fifteen  ounces 
per  diem,  which  should  be  taken  between  meals.  For  the  relief  of 
thirst  in  these  cases  various  measures  are  employed,  such  as  are 
described  on  page  36. 

In  Germany  the  dry  diet  has  been  tried  extensively  in  some  cases, 
especially  those  of  gastric  dilatation  and  cases  of  chronic  effusion 
into  the  joints  and  in  the  peritoneal  cavity.  There  are  many  forms 
of  disease  in  which  it  is  well  to  temporarily  restrict  very  much  the 
quantity  of  fluid  consumed,  but  it  is  hardly  ever  justifiable  to  do  so 
to  the  degree  recommended  by  enthusiastic  advocates  of  the  "  dry 
cure,"  among  whose  patients  fatal  cases  of  scurvy  have  occurred  as 
well  as  cases  of  fever  with  a  temperature  sometimes  amounting  to 
104°  F,  The  conditions  in  which  the  quantity  of  fluid  drunk  should 
be  especially  restricted  are  gastric  dilatation,  chronic  serous  effu- 
sions, flatulent  dyspepsia  due  to  indulgence  in  sweets,  coffee,  tea, 
etc.,  some  few  cases  of  obesity,  and  aneurism  of  the  aorta  (compare 
Tufnell's  treatment,  page  457). 

Schroth's   Method. 

The  dry  cure  of  the  yeoman  John  Schroth  has  achieved  some 
notoriety  in  Europe,  where  several  "institutes"  have  been  estab- 
lished for  its  practice.  It  is  a  rigorous  method  which  many  patients 
find  difficult  to  endure.  The  diet  is  gradually  reduced  in  quantity 
and  variety  at  first  for  a  few  days,  and  then  the  actual  "  cure  " 
is  begun,  which  consists  in  giving  no  fluid  at  all,  excepting  a  small 
glass  of  hot  wine  twice  a  day  for  as  many  days  as  the  patient  will 
endure  it.  Boiled  vegetables  are  allowed  for  dinner,  and  otherwise 
nothing  is  given  but  dry  bread.  Thirst  becomes  so  extreme  that  in 
three  or  four  days  the  patient  is  allowed  to  drink  hot  wine  freely  to 
quench  it,  after  which  the  quantity  of  fluid  is  again  cut  down  to  two 
small  glasses  a  day  until  the  patient  is  again  obliged  to  receive 
more. 

This  treatment  has  in  some  cases  been  carried  to  the  verge  of 
starvation  with  extreme  prostration  and  fever,  and  it  has  little  or 
nothing  to  recommend  it.  Even  fatal  scurvy  has  followed  its  use  at 
Kiel.  It  is  based  upon  the  theory  that  the  blood  becomes  more 
dense,  which  favours  osmosis  between  the  serum  and  the  surround- 


DIET   FOR   ATHLETIC   TRAINING.  703 

ing  lymph  and  tissues.  As  an  adjunct  to  the  treatment  hot  moist 
packing  is  employed. 

Jurgensen  modified  the  treatment  by  giving  from  one  third  to 
two  thirds  of  a  pound  of  lean  beef  with  bread  as  desired,  and  light  red 
wine.  It  has  been  found  by  this  writer  and  by  Bartels  that  proteid 
metabolism  is  undoubtedly  increased  by  the  dry  diet,  for  the  urine 
contains  nitrogenous  waste  in  as  large  a  proportion  as  when  the 
patient  is  upon  a  full  diet — in  some  cases  there  is  even  more  than 
the  normal. 

Upon  slowly  resuming  the  accustomed  diet  a  considerable  gain 
in  weight  compensates  for  previous  loss,  which  is  attributed  in  part 
to  restoration  of  water  to  the  tissues.  Bartels  noted  an  increase  in 
urea  which  was  greatest  immediately  after  the  treatment.  The  con- 
siderable rise  of  temperature  (104°  F.)  which  accompanies  this  treat- 
ment is  explained  by  the  facts  that  but  little  water  is  evaporated 
from  the  lungs  and  skin,  and  that  the  body  heat  is  retained  by  the 
hot  packs. 

The  treatment  has  been  applied  with  some  success  in  obstinate 
cases  of  syphilis,  gastric  dilatation,  chronic  rheumatism,  and  chronic 
peritonitis. 

DIET  FOR  ATHLETIC  TRAINING. 

The  object  of  dietetic  "  training  "  in  athletics  is  to  fit  men  either  for 
feats  of  great  muscular  endurance  and  strength  or  for  exhibitions  of 
dexterity  requiring  accurate  and  quick  muscular  movements  and 
nerve  control.  The  method  of  training  naturally  differs  consider- 
ably according  to  the  object  to  be  attained.  Professional  athletes, 
who  are  more  or  less  constantly  employed  in  exhibitions  of  strength 
or  muscular  skill,  are  obliged  to  adopt  very  regular  habits  of  life  in 
regard  to  sleep,  bathing,  and  diet,  and  abstinence  from  the  excessive 
use  of  tobacco  and  strong  drink.  In  addition,  when  they  enter  spe- 
cial contests  requiring  continued  feats  of  endurance,  as  in  prolonged 
bicycle  races  or  walking  matches,  for  example,  they  have  to  undergo 
a  period  of  special  training  for  several  weeks  before  the  contest. 
Young  men  who  devote  themselves  to  athletic  sports  in  college 
usually  do  so  for  a  comparatively  limited  period,  and  are  not  sub- 
jected to  such  special  strain  or  feats  of  endurance  excepting,  perhaps, 
in  boat  races,  which  are  comparatively  of  short  duration.  As  a 
general  rule,  from  six  to  ten  weeks  is  ample  time  to  cover  their 
course  of  special  dietetic  training,  although  they  usually  exercise 
ordinary  care  in  such  matters  for  a  longer  period  before  their 
contests. 

The  physiological  objects  to  be  attained  by  any  system  of  dietetic 
training  are  to  reduce  the  fat  and  water  contained  in  the  tissues  of  the 
body,  to  increase  the  functional  activity  of  the  muscles,  to  train  both 
47 


704 


RATIONS,    DIETARIES. 


muscles  and  nerves,  and  improve  the  breathing  power  or  "wind"  and 
the  condition  of  the  skin.  This  is  accomplished  by  carefully  reg- 
ulated diet,  systematic  exercises  directed  to  the  increase  of  oxidation 
processes,  and  the  more  perfect  elimination  of  waste  matter  from 
the  system. 

Rigorous  dietetic  training  should  be  conducted  with  great  care 
and  supervised  only  by  those  who  are  experienced  in  such  matters, 
for  any  system  carried  to  excess  may  cause  too  great  a  reduction  in 
weight,  and  its  object  will  be  defeated  by  breaking  down  the  indi- 
vidual at  the  moment  of  critical  contest  or  laying  the  foundation  for 
future  organic  weakness  anddisease.  The  heart  may  become  hyper- 
trophied  and  subsequently  fail  in  accommodation. 

It  may  be  observed,  however,  that  much  of  the  ill  effect  of  ath- 
letic training  may  be  due  not  so  much  to  any  particular  form  of 
exertion  or  to  being  trained  "too  fine"  in  diet,  but  to  the  fact  that 
the  system  brings  to  light  constitutional  weaknesses  which  were 
unsuspected  until  revealed  by  unwonted  effort — in  short,  the  system 
involves  survival  of  the  fittest. 

The  transition  from  ordinary  diet  to  that  of  any  training  system 
should  be  made  gradually,  and  the  return  to  the  usual  diet  after  a 
period  of  rigid  training  should  be  similarly  slow.  For  the  first  two 
or  three  weeks  of  training  athletes  usually  lose  in  weight  an  amount 
proportionate  to  their  previous  condition  of  robustness,  but  after 
several  weeks  an  equilibrium  should  be  reached  in  which,  upon  an 
established  diet,  the  body  weight  remains  practically  the  same  while 
the  muscular  strength  and  vigour  and  power  of  endurance  increase; 
the  complexion  improves  in  appearance,  the  skin  becomes  clear,  the 
muscles  become  firmer,  and  all  superfluous  fat  disappears. 

While  individual  dietaries  differ  in  training  for  the  various  forms 
of  contest,  most  of  them  include  lean  meat,  chiefly  rare  or  "under- 
done," either  roasted  or  broiled  ;  the  bread  should  be  dry  or  toasted; 
a  moderate  quantity  of  potatoes  and  green  fresh  vegetables  and  fruits 
are  usually  allowed.  The  class  of  foods  to  be  especially  forbidden 
are  sweets,  pastry,  entrees,  rich  puddings,  sour  pickles,  and  condi- 
ments. For  beverages,  weak  tea  or  coffee  may  be  allowed,  although 
sometimes,  where  the  object  of  training  is  the  attainment  of  special 
skill  in  feats  of  delicate  balancing,  all  forms  of  nerve  stimulants 
including  tea,  coffee,  tobacco,  and  should  be  prohibited.  Chocolate 
and  cocoa,  if  not  too  sweet,  may  be  sometimes  allowed,  and  in  some 
training  systems  the  use  of  light  beer  and  light  wine  in  moderation 
is  included,  but  strong  alcoholic  spirits  are  absolutely  forbidden.  As 
a  rule,  three  meals  a  day  at  intervals  of  about  six  hours  are  recom- 
mended. 

The  ancient  Greek  and  Roman  athletes  used  to  train  very  largely 
upon  a  dry  diet,  which  at  first  consisted  of  fresh  cheese,  dried  figs, 


DIET   FOR   ATHLETIC   TRAINING. 


705 


and  preparations  of  wheat.  Later  they  ate  such  meats  as  pork,  beef, 
and  goat  flesh. 

Parkes  gives  the  amount  of  fluid  which  may  be  allowed  as  about 
five  pints  in  winter  and  six  in  summer,  a  little  over  one  fourth  of 
which  is  contained  in  the  food.  Drink  should  not  be  taken  either 
shortly  before  exercise  or  during  meals.  If  the  mouth  be  well  rinsed 
before  drinking,  less  fluid  will  be  required,  and  what  is  taken  should 
be  drunk  slowly. 

The  use  of  tobacco,  particularly  in  the  form  of  cigarette  smoking, 
must  be  forbidden,  and  as  alcohol  in  excess  lessens  the  power  of  sus- 
tained muscular  exertion,  not  over  two  ounces/^r  diem  can  be  allowed. 

The  following  dietaries  of  training  have  been  kindly  furnished  me 
by  Dr.  Hartwell,  who  has  had  much  personal  experience  in  such 
matters : 

DIETARY   OF   THE   BOAT   CREW   AT   YALE   UNIVERSITY. 

From  March  ist  till  June  loth  (ten  weeks  and  a  half),  the  hours 
of  work  are  from  4  to  7  p.  m.,  with  exercise  for  an  extra  half  hour  or 
more  at  such  odd  times  as  recitations  may  permit.  During  this  pe- 
riod the  following  regulations  of  the  training  table  are  observed : 

Breakfast,  7.30  a.  m. 

Fruit. — Oranges,  tamarinds,  figs,  and  dates. 

Cereals. — Oatmeal  or  one  of  the  many  preparations  of  wheat ;  a 
rich  milk  (not  cream)  and  sugar  are  allowed  with  this.  Toast.  No 
hot  breads  are  allowed. 

Meats. — Beefsteak  (usually  rare),  chops,  stews,  hash.  Once  or 
twice  a  week  some  salt  meat,  as  bacon  or  ham,  is  allowed,  and  with 
it  usually  liver. 

Potatoes. — Stewed,  browned,  and  baked. 

Eggs. — Served  in  all  styles,  except  fried  (unless  with  the  ham). 
Eggs  appear  in  some  form  about  four  mornings  a  week. 

The  meats  are  varied,  steak  or  chops  alternating  one  of  the  others. 

Fluids. — Water,  milk,  tea  on  special  occasions  for  some  individual 

man.     The  water  is  boiled  and  poured  while  hot  on  the  oatmeal. 

On  cooling  it  has  about  the  consistence  of  rich  milk  and  a  strong 

flavour  of  the  oatmeal. 

Dinner. 

Soups. — All  varieties,  including  oyster  stews  and  clam  broths. 

Meat's.— "^odiiX.  beef,  mutton,  turkey,  chicken.  Gravies  are  but 
little  used.     Two  kinds  of  meat  are  always  served.  * 

Fish,  broiled  or  boiled,  is  served  twice  a  week. 

Vegetables. — Potatoes  (mashed  or  boiled).  Tomatoes,  stewed  or 
sometimes  raw.  Beans,  peas,  corn  (occasionally).  Two  vegetables 
besides  potatoes  are  usually  served. 


7o6 


RATIONS.   DIETARIES. 


Bread. — Toast. 

Dessert. — Puddings — rice,  bread,  tapioca;  but  little  butter  is  al- 
lowed in  their  preparation. 

Fruit. — Same  as  breakfast,  with  berries  and  cantaloupe  in  season. 
Baked  apples. 

Fluid. — Same  as  breakfast. 

Supper  {one  hour  after  roiving — /.  e.,from  7  /<?  8.15  p.  M.). 

Cereals. — Same  as  breakfast. 

Meats. — Chops,  stews,  cold  meats  from  dinner.     Rarely,  beefsteak. 

Potatoes. — Stewed  or  baked. 

Eggs. — All  styles,  about  three  times  a  week,  usually  not  on  same 
day  as  for  breakfast. 

Fluids. — Same  as  breakfast.  Bass's  ale  for  men  who  are  getting 
"  fine  "  and  for  whole  crew  after  especially  hard  day's  work. 

Ale  and  milk  are  never  taken  at  same  meal. 

For  three  weeks  following  June  loth  the  crew  is  at  New  London 
in  final  preparation  for  their  race.  The  programme  is  then  some- 
what changed. 

Breakfast  is  served  at  the  same  hour  and  consists  of  the  same 
variety  of  food  as  before. 

The  morning  work  is  from  9.30  or  10  to  11.30  or  12. 

Dinner,  with  same  menu  as  before,  is  served  at  12.30  or  i  p.  M. 

Luncheon. — The  afternoon  till  4.30  is  spent  in  loafing — often  in 
the  water  in  the  steam  launch.  At  that  hour  a  lunch  of  cold  meat, 
stewed  or  baked  potatoes,  milk,  and  toast  is  served.  The  afternoon 
work — which  is  the  hard  work  of  the  day — begins  from  forty-five  to 
sixty  minutes  after  the  lunch  and  continues  for  about  two  hours, 
more  or  less,  depending  on  its  severity.  Forty-five  minutes  after  this 
work  cold  oatmeal  or  other  cereal,  with  toast  and  milk,  is  served. 

Many  of  the  men  are  allowed  ale  every  night  during  the  final 
three  weeks,  either  with  the  late  supper  or  an  hour  later — 9.30,  on 
retiring. 

Quantity  of  Food  and  Fluid. — There  is  no  limit  set  to  the  quantity 
of  food.  The  fluids,  however,  are  limited  to  three  glasses  at  a  meal, 
with  but  little  drink  between  meals.  Of  late  years  this  is  becom- 
ing changed,  and  in  hot  weather,  when  the  men  are  perspiring  freely, 
more  fluid  is  allowed.  To  counteract  the  constipating  effect  which 
training  has  upon  some  men,  stewed  prunes  are  served  for  either 
breakfast  or  supper. 

The  training  table  of  the  present  day,  as  given  above,  is  far 
more  liberal  than  five  or  ten  years  back,  and  it  is  aimed  to  regulate 
it  on  a  rational  basis.  What  few  statistics  are  at  command  seem  to 
show  that  the  new  is  an  improvement  on  the  old  system,  and  cases 
of  overtraining  are  less  frequent  and  less  serious  now  than  formerly. 


DIET   AND   OCCUPATION. 


707 


It  is  the  opinion  of  J.  W.  White  that  "an  ordinary  farmhouse 
table  with  its  midday  dinner  and  early  tea  will  rarely  (with  the  ex- 
ception of  coffee,  hot  cakes,  pastry,  and  fried  meats)  offer  anything 
which  should  be  excluded  from  a  rational  training  diet  as  it  is  at 
present  understood." 

DIET   OF   YALE   FOOTBALL    TEAM. 

"The  diet  of  the  football  team  is  practically  the  same  as  for  the 
crew  except  for  lunch,  which  is  eaten  at  i  p.  m.,  the  practice  taking 
place  from  2.30  to  3.45  or  4  p.  m.  This  one-o'clock  meal  consists  of 
cold  meat,  one  chop  or  eggs,  hot  broth  or  bouillon,  and  toast.  Milk 
and  oatmeal-water  are  drunk.  Apple  sauce  is  sometimes  allowed  " 
(Hartwell). 

Chambers  gives  the  following  example  of  a  diet  used  by  pugilists: 

7  A.  M.  Light  breakfast:  oatmeal  with  little  or  no  milk  and  sugar; 
one  to  three  eggs,  poached  or  raw;  a  cup  of  tea  with  little  or  no 
milk  or  sugar;  a  slice  or  two  of  toast.  The  eggs  may  be  varied  by 
a  rare  or  well-broiled  chop. 

12  NOON.  Dinner  (following  a  half  hour  of  rest) :  roast  beef  or 
mutton  and  vegetables;  cup  custard  and  plum  pudding.  A  heavy 
dinner  may  be  eaten,  unless  it  is  desired  to  reduce  the  weight.  Old, 
mixed,  or  Bass's  ale  is  allowed,  but  only  a  little  water  should  be 
drunk,  for  it  favours  obesity.  If  thirst  is  annoying,  a  pebble  may 
be  carried  in  the  mouth  to  increase  the  flow  of  saliva. 

An  hour  or  two  of  rest  should  be  taken  after  dining. 

6  p.  M.  Light  supper:  toast,  a  mutton  chop  or  an  egg,  a  vege- 
table, and  a  cup  of  tea. 

The  dietetic  training  of  jockies  is  merely  for  the  purpose  of  re- 
ducing weight,  and  more  depends  on  their  eating  a  small  quantity  of 
food  than  upon  its  restriction  in  variety.  They  should  make  their 
fare  chiefly  bread  and  meat,  and  abstain  from  much  fluid. 

.  Chambers  points  out  that  men  who  have  brief  holidays  in  the 
country  often  fail  to  get  the  maximum  good  of  their  outdoor  life, 
because  they  are  not  in  proper  condition  for  it.  If  a  shooting  or 
walking  trip  is  to  be  undertaken  for  a  week  or  two,  it  is  well  to  ab- 
stain for  a  fortnight  beforehand  from  eating  elaborate  dinners,  and 
to  leave  off,  sweets  and  pastry  and  live  on  a  drier  diet  than  usual. 

DIET  AND  OCCUPATION. 

There  are  some  occupations  which  are  more  or  less  closely  con- 
nected with  dietetics.  Workers  in  lead,  plumbers,  painters,  polishers, 
pottery  glaziers,  ^/ a/.,  should  be  taught  to  be  very  careful  to  cleanse 
the  clothing,  hands,  and  especially  their  finger  nails,  before  eating. 
The  soft  crumb  of  bread  getting  under  the  nails  easily  becomes  con- 


7o8  RATIONS,   DIETARIES. 

laminated  with  lead  salts,  which  by  this  means  are  conveyed  to  the 
stomach,  where  the  white  lead  carbonate,  which  is  insoluble  in  water, 
is  dissolved  by  the  gastric  juice  into  a  more  dangerous  chloride. 
Workers  in  dye  stuifs,  artificial  flowers,  green  wall  papers,  and  othec 
materials  in  which  arsenic  is  used,  should  be  similarly  careful,  and 
should  never  be  permitted  to  bring  their  food  into  the  workrooms. 

Some  occupations — those  of  foundrymen,  stokers,  and  porcelain 
manufacturers — necessitate  exposure  to  extremely  high  temperatures. 
Profuse  sweating  results,  and  thirst.  The  thirst  is  quenched  by  sub- 
sequently drinking  enormous  quantities  of  fluid,  which  should  be 
water  or  oatmeal  water,  not  too  cold,  rather  than  beer  or  other  alco- 
holic beverages.  Their  lives  at  best  are  apt  to  be  shortened  by  the 
suddenness  and  severity  of  the  changes  to  which  their  kidneys  and 
circulation  are  subjected,  and  a  resort  to  alcohol  is  soon  fatal. 

Tea  tasters  acquire  more  or  less  poisoning,  although  they  do  not 
swallow  the  beverage,  for  a  good  deal  is  absorbed  by  the  mucous 
membrane  of  the  mouth.  The  symptoms  are  insomnia,  nightmare, 
headache,  "nervousness,"  tremors,  dyspepsia,  and  constipation. 
Even  smelling  the  tea  infusions  constantly  is  poisonous  to  some  sen- 
sitive persons  (Chambers).  To  mitigate  the  danger  they  should  eat 
abundantly  before  exposing  themselves  to  the  noxious  effects  of 
their  occupation. 

Among  other  diseases  occasioned  by  the  handling  of  food  prod- 
ucts may  be  mentioned  the  grocer's  itch,  from  handling  low  grades 
of  sugar  (now  much  less  common  than  formerly,  owing  to  better 
methods  of  refining),  and  the  bronchial  diseases  produced  by  the  in- 
halation of  flour  and  grain  dust  in  grist  mills  and  grain  elevators. 

There  are,  in  addition,  many  occupations  which  directly  interfere 
with  the  proper  digestion  of  food,  such  as  those  of  tailors  and  shoe- 
makers, whose  cramped  positions  compress  the  abdominal  viscera 
and  impede  full  respiratory  action.  Their  discomfort  from  dyspep- 
sia and  flatulency  teaches  them  to  avoid  eating  vegetables  and 
sweets. 

All  occupations  conducted  in  close,  ill-ventilated  apartments  are 
injurious  by  depriving  the  individual  of  sufficient  oxygen  to  consume 
the  food  products  in  the  system. 

DIET  FOR   BRAIN  WORKERS. 

Persons  who  are  constantly  employed  in  mental  labour,  and  con- 
sequently lead  sedentary  lives,  usually  find  from  experience,  sooner 
or  later,  that  they  must  pay  attention  to  their  diet  in  order  to  main- 
tain the  best  condition  of  health.  Energy  diverted  for  mental  work 
is  apt  to  be  at  the  expense  of  digestive  activity,  consequently  it  is 
important  that  the  meals  should  be  of  such  a  character  as  not  to 


DIET   FOR   BRAIN   WORKERS. 


709 


unduly  tax  the  stomach  and  intestines.  As  a  rule,  meat  should  be 
eaten  but  once  a  day,  and  then  only  in  moderation,  and  persons  who 
are  not  of  strong  physique  do  well  to  replace  meat  for  a  time  by 
other  varieties  of  animal  food  which  require  less  time  and  energy  for 
their  digestion.  Milk,  eggs,  fish,  and  abundant  fresh  fruit,  with  light, 
porous,  and  dry  bread,  should  constitute  their  staple  dietary. 

Brain  workers  may  suffer  from  lithaemia,  which  is  undoubtedly 
often  due  to  other  causes  than  dietetic  errors,  such  as  anxiety,  worry, 
and  overwork.  Patients  of  this  class  do  better  with  a  good,  full, 
nourishing  diet  than  by  any  attempt  at  restriction,  provided  their 
food  is  thoroughly  well  cooked  and  is  light  and  digestible.  They 
should  avoid  saccharine,  fatty,  and  purely  starchy  dishes,  but  they 
need  meat,  and  may  have  a  moderate  variety  of  fruits  and  fresh 
green  vegetables. 

The  brain  contains  nearly  three  times  as  much  fat  as  may  be 
found  in  the  muscles,  and  in  nerves  an  even  larger  percentage  is 
present.  For  this  reason  carbohydrates  and  fats  are  of  value  for 
brain  workers  who  are  not  lithaemic,  and  the  latter  food  may  be  sup- 
plied in  the  form  of  cream,  butter,  or  fat  well-cooked  bacon. 

It  is  believed  by  some  writers  that  the  fact  that  fat  is  good  food 
for  brain  workers  depends  upon  the  ease  with  which  it  develops 
energy  with  less  complex  metabolism  than  starches,  and  the  nervous 
energy  of  many  Americans  is  sometimes  attributed  to  the  greater 
consumption  of  fat  in  this  country  as  compared  with  Continental 
Europe  and  England. 

The  popular  idea  that  fish  has  some  specific  action  as  a  brain  food 
on  account  of  the  phosphorus  which  is  present  in  some  species  in 
considerable  amount,  and  which  is  also  an  ingredient  of  nerve  tissue, 
is  not  founded  upon  fact.  Fresh  fish  is  very  wholesome,  and  by  re- 
placing meat  in  the  menu  less  labour  is  required  of  the  digestive 
organs,  and  some  forms  of  fish  contain  abundant  fat  or  oil,  but  aside 
from  this,  fish  cannot  be  said  to  be  especially  a  brain  food.  It  has 
been  pointed  out  elsewhere  (page  11 1)  that  the  tribes  of  men  who 
live  very  largely  upon  fish  are  by  no  means  noted  for  their  intellec- 
tual development. 

For  brain  workers  who  desire  to  keep  in  good  health  the  alterna- 
tive is  either  to  take  at  least  two  hours  of  rest  after  a  noon  dinner  or 
else  to  eat  a  light  meal  at  noon  and  dine  later  in  the  day.  This 
fact  should  be  recognised  in  the  arrangement  of  meals  for  college 
students.  It  is  far  better  during  the  active  hours  of  brain  work 
to  supply  only  such  food  as  is  necessary  for  prompt  force  produc- 
tion without  calling  upon  the  digestive  organs  for  the  expendi- 
ture of  much  energy  in  elaborating  food  which  is  only  needed  for 
storage. 

Breakfast  should  consist  of  fresh  fruit,   a  cereal  with  cream,  a 


710 


RATIONS,   DIETARIES. 


poached  egg,  a  bit  of  broiled  (not  fried)  fish,  or  a  rasher  of  bacon, 
with  tea  or  coffee. 

Luncheon  may  comprise  such  articles  as  a  roast  potato  with  butter 
and  cream,  or  beans  and  bacon,  one  or  two  light  sandwiches  made 
with  a  slice  of  game  or  a  relish  of  some  sort,  cheese,  lettuce  or  salad," 
and  a  baked  apple  and  cream. 

Dinner  should  be  a  hearty  meal  with  soup,  a  roast  or  joint,  vege- 
tables, and  a  light  farinaceous  pudding.  If  evening  work  must  be 
done,  there  should  be  an  interval  of  at  least  an  hour  for  rest  and 
recreation.  A  generous  meal  is  easier  digested  after  work  is  done, 
and  makes  the  best  preparation  for  the  next  day's  toil. 

A  Work  Ration  for  a  Professional  or  Literary  Man  (Mrs.  E.  H.  Richards). 


Bread 

Meat 

Butter 

Sugar 

Milk 

Oysters 

Soup 

Potatoes 

Eggs 

Oatmeal 

Cream 

Fruit 

Additional  liquid- 


-tea,  coflfee,  or  water 


Total 


Ounces. 


I6 
l6 

I 

4 
8 

4 
4 
6 

3 

2 


30 


Proteid. 


Grammes. 
32.0 
50.0 


18.0 
7.0 
4.0 

3-0 
10. o 

I.O 


127.0 


Fats. 


Grammes. 

3-0 
30.0 
25.0 

18.0 
1.0 
30 

9.0 
0.5 
6.5 


96.0 


Carbo- 
hydrates. 


Grammes, 
258.0 


IIO.O 
22.0 


38.0 

4.0 
1.0 

50.0 


483-0 


Calories. 


1,216.6 

481.0 

230.0 

451.0 

329.6 

37-8 

44.0 

168. 1 

123.8 

25-1 

70.1 
207.1 


3.384-2 


Overeating  should  be  studiously  avoided.  Loading  the  system 
with  incompletely  assimilated  food  products  impairs  intellectual  ac- 
tivity and  exhausts  the  nervous  system.  If  some  special  task  re- 
quires long  hours  of  work  and  absorbing  concentration,  it  may  be 
better  to  eat  but  little  at  a  time,  and  take  one  or  two  extra  lunches 
during  the  day.  When  such  labour  proves  fatiguing,  alcohol  may  be 
temporarily  employed,  but  only  with  the  meals,  and  not  as  a  stimu- 
lant between.  The  quantity  may  be  regulated  somewhat  by  the  ap- 
petite, but  it  should  never  be  large.  If  a  glass  or  two  of  claret  or 
Burgundy  or  of  malt  liquor  with  lunch  or  dinner  improves  the  ap- 
petite for  solid  food  and  aids  its  digestion,  it  is  beneficial,  for,  as 
Chambers  wrote,  ''it  stays  the  weariness  of  the  system  and  allows 
the  nerve  force  to  be  diverted  to  the  digestion  of  the  meal  "  but  to 
labour  on  and  "  continue  to  take  this  anaesthetic  between  meals  is 
inconsistent";  and  "  when  any  extraordinary  mental  toil  is  tempo- 
rarily imposed,  extreme  temperance  or  even  total  abstinence  should 
be  the  rule,  for  mental  activity  makes  the  brain  bear  less  alcohol 
than  rest  and  relaxation." 


DIET   IN   COMMERCIAL   LIFE.  7II 

The  varieties  of  beverages  named  are  all  better  than  port,  sherry, 
or  the  stronger  liquors. 

It  is  a  mistake  to  suppose  that  violent  muscular  exercise  is  an 
offset  to  mental  strain.  Very  moderate  exercise  combined  with 
abundant  fresh  air  and  with  mental  diversion  and  relaxation  are 
more  beneficial,  and  do  not  add  one  kind  of  material  exhaustion  to 
another  already  present. 

Tobacco  and  coffee,  like  alcohol,  are  stimulants  which  are  use- 
ful in  such  cases  only  in  proportion  to  the  moderation  in  which  they 
are  employed.  Tea  may  be  allowed  in  the  earlier  part  of  the  day  if 
it  does  not  cause  wakefulness. 


DIET  IN  COMMERCIAL  LIFE. 

The  responsibilities  and  anxieties  of  active  business  life  are  apt 
at  times  to  react  unfavourably  upon  digestion,  producing  dyspepsia, 
headache,  constipation,  and  biliousness.  As  a  rule,  there  are  few 
patients  less  willing  to  listen  to  advice  in  regard  to  diet  and  habits  of 
life  than  the  overworked  business  man  engaged  in  the  strife  of  active 
competition  and  with  large  financial  interests  at  stake.  He  expects  a 
dinner  pill  or  laxative  or  the  latest  fashionable  "tonic  "  to  counter- 
act the  persistent  violation  of  the  simplest  dietetic  and  hygienic  laws, 
and,  obtaining  temporary  relief,  goes  on  overtaxing  his  alimentary 
canal,  liver,  and  nervous  system,  laying  the  foundation  of  more  seri- 
ous ills,  such  as  lithaemia,  arterio-sclerosis,  or  possibly  gout,  gravel, 
or  cirrhosis.  The  increasing  prevalence  of  chronic  Bright's  disease  in 
this  country  is  by  some  authors  of  large  experience  attributed  to 
such  causes.  Imperfectly  oxidised  waste  materials  in  the  circula- 
tion may  irritate  kidneys  and  vascular  system  alike,  and  long-con- 
tinued excitation  eventually  results  in  structural  changes. 

While  prescribing  remedies  for  individual  symptoms  the  physician 
should  not  neglect  to  give  wholesome  counsel  concerning  diet,  and 
such  advice,  however  little  heeded  by  itself,  will  sometimes  be  re- 
garded as  an  essential  part  of  other  remedial  measures,  and  accepted 
accordingly.  The  too  hasty  consumption  of  food,  the  neglect  of 
securing  proper  action  of  the  bowels,  and  carrying  the  concerns  and 
worries  of  the  counting-house  to  the  table,  combined  with  loss 
of  sleep  and  of  outdoor  exercise,  are  the  principal  difficulties  which 
this  class  of  patients  must  contend  against.  Three  good  meals  a 
day  should  be  eaten.  The  breakfast  should  be  substantial,  compris- 
ing meat  or  eggs  or  fish  with  some  cereal  and  fresh  fruit ;  and  dinner 
should  be  the  last  meal  of  the  day,  eaten  preferably  late — at  half  past 
six  or  seven  o'clock — allowing  an  interval  before  the  meal  for  recrea- 
tion or  diversion. 

The  lunch  should  be  the  lightest  meal  of  the  day,  for  the  reason 


712 


RATIONS,   DIETARIES. 


that  it  is  diflficult  for  many  to  take  it  always  at  a  fixed  hour,  and  still 
more  difficult  to  allow  sufficient  time  for  due  mastication  and  diges- 
tion. Sydney  Smith  once  said,  referring  to  the  bad  habit  of  hasty 
eating,  that  "many  a  man  digs  his  grave  with  his  teeth."  It  is  not 
necessary,  nor  is  it  advisable,  to  eat  meat  three  times  a  day,  and 
many  of  these  patients  who  are  made  dyspeptic  by  eating  meat  and 
vegetables  together  find  that  they  have  less  flatulence  and  discom- 
fort after  meals  if  they  take  these  classes  of  foods  independently, 
eating  meat  and  no  vegetables  or  sugars  at  one  meal,  and  vege- 
tables without  meat  at  another.  The  reason  for  this  should  be  ex- 
plained to  them — namely,  that  carbohydrates,  digested  only  by  alka- 
line saliva  and  pancreatic  fluid,  may  interfere  with  the  acid  digestion 
of  animal  food  in  the  stomach.  The  luncheon  should  consist,  there- 
fore, of  simple  farinaceous  food  with  one  or  two  plainly  cooked  vege- 
tables or  a  salad  and  a  relish  of  some  sort. 

Alcoholic  stimulants  of  any  kind  are  not  required,  except  to 
counteract  exceptional  fatigue,  and,  as  a  rule,  these  patients  are 
better  without  their  habitual  use.  If  allowed,  they  should  be  drunk 
at  dinner  only.  Malt  liquors  taken  at  luncheon  are  apt  to  cause 
drowsiness  and  dulness  in  the  afternoon. 

As  adjuncts  to  the  dietetic  treatment  other  measures  should  not 
be  neglected.  Cold  bathing  with  vigorous  rubbing  is  desirable  on 
rising,  and  an  occasional  Russian  or  Turkish  bath  may  be  service- 
able if  there  is  a  tendency  to  heavily  loaded  urine  and  biliousness. 
Exercise  in  the  open  air  is  very  important.  Too  much  walking  is 
fatiguing,  and  apt  to  be  monotonous.  Bicycling  is  much  better.  It 
furnishes  more  active  exercise  and  diverts  the  mind  ;  but  horseback 
riding  is  preferable,  even  if  it  can  be  indulged  in  but  once  a  week. 
Rowing  also,  when  it  can  be  had,  is  capital  exercise,  but  it  is  not  avail- 
able for  the  middle-aged  or  older  men,  who  constitute  the  majority 
of  the  class  of  patients  under  discussion. 

The  bowels  should  be  kept  active,  and  fresh  fruit  and  abundant 
draughts  of  pure  water  are  the  best  means  for  this  purpose. 

DIET    AND    TRAVEL. 

In  travelling  one  is  often  placed  in  circumstances  in  which  it  is 
difficult  or  impossible  to  obtain  wholesome  food,  and  must  either  be 
content  with  badly  cooked  or  positively  repugnant  food,  or  go  with- 
out. Under  such  conditions  it  is  a  decided  advantage  to  have  a 
varied  taste,  so  that  something  may  be  found  which  will  not  disgust. 

It  is  difficult  to  give  any  but  the  most  general  directions  for 
circumstances  which  are  so  various.  It  is  a  common  fault  to  eat  too 
much  when  travelling,  and  the  lack  of  exercise  combined  with  an 
excess  of  food  results  in  indigestion,  constipation,  and  biliousness. 


DIET   IN   PREGNANCY. 


713 


Sea  voyages  sometimes  benefit  invalids  and  dyspeptics  more  than 
the  healthy,  for  the  latter,  if  not  seasick  at  first,  are  very  apt  to 
overeat,  and  suffer  in  consequence. 

The  "  stand-up  lunch  counters  "  of  American  railway  stations 
freighted  with  doughnuts,  tough  ham,  and  pie  are  a  constant  invita- 
tion to  dyspepsia  with  the  hurried  eating  of  such  indigestible  articles 
as  they  afford,  but  which  the  more  recent  introduction  of  dining  cars 
is  fortunately  replacing,  at  least  for  those  whose  means  allow  them 
to  consult  the  best  interests  of  their  digestive  organs. 

In  warm  climates  olive  oil  may  be  often  obtained  and  made  to 
replace  rancid  butter  upon  baked  potatoes.  Much  garlic  may  cause 
diarrhoea  and  colic  in  those  unaccustomed  to  its  use,  but  mustard 
will  counteract  its  effect  (Chambers).  Lemon  juice  also  forms  a 
wholesome  relish  and  aids  in  checking  diarrhoea.  It  is  well  to  avoid 
raw  or  imperfectly  cooked  ham  and  sausage  of  every  sort,  for  fear 
of  parasitic  infection.  If  the  food  is  inevitably  greasy  its  digestion 
may  be  promoted  by  the  use  of  condiments,  such  as  vinegar,  Cay- 
enne, tobacco,  or  lemon  juice.  All  milk  as  well  as  water  drunk  should 
be  previously  boiled. 

Fresh  fruits,  crackers,  bread,  cold  meats,  soft-cooked  eggs,  and 
milk  will  be  found  to  comprise  the  most  digestible  articles  for  a 
railway  journey,  and  invalids  or  travellers  who  have  wandered  far 
from  good  food  supplies  do  well  to  carry  some  of  the  concentrated 
preparations  which  with  the  aid  of  a  little  hot  water  may  be  made 
into  a  nutritious  beverage,  such,  for  example,  as  malted  milk  and 
cereals,  beef  meal  or  beef  jelly,  chocolate,  condensed  coffee,  meat 
extracts,  etc.,  besides  which  there  is  an  almost  inexhaustible  variety 
of  canned  foods,  meats,  vegetables,  and  fruits  from  which  the 
traveller  or  explorer  may  replenish  his  table.  For  infants  sterilised 
milk  may  be  carried  which  will  keep  fresh  for  ten  days,  or  canned 
milk  may  be  provided  for  a  longer  period. 

Lime  tablets  are  prepared  which  may  be  conveniently  used  in 
travelling  when  fresh  lime  water  i^  likely  to  be  required  for  dilution 
of  milk  or  for  use  in  seasickness. 

DIET    IN     PREGNANCY. 

It  is  not  customary  to  adopt  any  definite  system  of  diet  for  preg- 
nancy unless  complications  arise.  If  serious  vomiting  occurs  in  the 
early  months,  this  should  be  treated  in  the  manner  described  on 
page  518.  If  albuminuria  is  discovered,  meat  and  other  nitrogenous 
food  must  be  restricted,  in  accordance  with  the  directions  given 
under  albuminuria  (page  470).  If  the  patient  becomes  very  anemic, 
meat  should  be  prescribed  (page  460). 

The  "  longings "  of   pregnant  women    for    various   indigestible 


714 


Rations,  dietaries. 


articles,  such  as  pickles,  chalk,  etc.,  are  largely  mythical,  and  occur, 
if  at  all,  only  as  an  accompaniment  of  a  general  hysterical  con- 
dition, not  as  a  peculiarity  of  the  period  of  pregnancy.  Pregnant 
women,  however,  should  live  simply  and  avoid  foods  which  are, 
likely  to  produce  dyspepsia,  heartburn,  and  colic,  such  as  sweets, 
pastry,  fried  food,  rich  sauces,  spiced  dishes,  and  heating  drinks. 
They  are  very  apt  to  suffer  from  constipation,  in  which  case  fruits 
and  coarse  cereals,  such  as  oatmeal  or  wheaten  grits,  may  be  of 
service  (page  548).  The  stomach,  especially  at  night,  should  not  be 
overloaded. 

The  idea  formerly  prevalent  that  pregnant  women  need  to  eat 
food  containing  abundant  phosphates  and  lime  salts,  to  furnish  the 
embryo  with  material  for  making  bones,  as  a  hen  eats  lime  to  make 
egg  shells,  is  no  longer  accepted.  The  salts  in  question  are  abun- 
dantly contained  in  an  ordinary  mixed  diet,  such  as  any  pregnant 
woman  may  eat,  if  plainly  cooked. 

Another  theory,  equally  ingenious  and  directly  opposed  to  the 
one  above  mentioned,  is  only  interesting  historically,  for  efforts  to 
aid  Nature  in  a  process  which  she  is  abundantly  competent  to  reg- 
ulate unaided  are  now  regarded  as  futile.  This  theory  was  that  the 
agonies  of  labour  would  be  less  severe  if  the  pregnant  woman  lived 
upon  a  diet  of  fruits  and  meat,  avoiding  bread  and  fresh  vegetables 
during  gestation,  on  the  ground  that  the  lime  salts  which  they  con- 
tain would  favour  early  ossification  of  the  infant's  bones,  and  thus 
make  the  labour  proportionately  difiicult. 

It  will  be  observed  that  the  first  theory  favours  the  child,  and 
the  second  the  mother,  but  practically  it  has  been  found  that  diet 
has  little  or  no  influence  either  way,  so  long  as  it  is  digestible, 
nourishing,  and  sufficient  to  keep  the  mother  in  good  general  con- 
dition. 

DIET    FOR    PUERPERAL    WOMEN. 

Within  the  past  thirty  years  a  revolution  has  been  experienced 
in  the  dietetic  treatment  of  puerperal  women,  and  they  are  no  longer, 
as  formerly,  kept  for  ten  days  or  a  fortnight  upon  a  diet  of  toast 
water,  "  slops,"  etc.,  with  the  idea  that  semistarvation  would  keep 
down  puerperal  fever  and  "  milk  fever."  This  change  is  largely  due 
to  methods  of  antiseptic  midwifery,  but  the  reaction  started  even 
earlier,  and  in  1876  Fordyce  Barker,  who  was  one  of  the  first  to  for- 
sake the  old  routine,  wrote  of  the  puerperal  state  :  "  I  have  never 
seen  the  slightest  evil  result  from  good,  ample,  judicious  alimenta- 
tion," and  "  I  have  had  patients  eat  a  good  piece  of  tenderloin  steak 
the  day  after  labour  with  a  relish,  and  with  happy  results." 

A  pregnant  woman  may  eat  her  ordinary  diet  up  to  the  com- 
mencement of  labour. 


DIET   FOR   PUERPERAL   WOMEN. 


71$ 


If  the  labour  is  greatly  protracted,  the  first  stage  lasting,  as  it 
exceptionally  does,  for  more  than  a  few  hours,  it  will  not  do  to  let 
her  strength  become  further  exhausted  from  lack  of  food,  and  she 
must  be  urged  to  take  stimulating  hot  broths,  gruels,  or  similar 
easily  digested  food.  Under  the  circumstances  she  is  naturally 
nervous  and  may  decline  all  food,  so  she  should  be  given  only  that 
which  is  quickly  swallowed  without  effort.  In  ordinary  cases,  how- 
ever, no  food  is  necessary  or  desirable  during  labour. 

Immediately  after  delivery  the  woman,  exhausted  by  muscular 
effort  and  agonising  pain,  and  possibly  also  under  the  influence  still 
of  an  anaesthetic,  needs  rest  rather  than  food,  and  as  she  is  more 
apt  to  be  thirsty  than  hungry,  she  may  drink  freely  of  water  or  Vichy. 

On  the  other  hand,  many  puerperal  complications,  including 
mania,  are  favoured  by  exhaustion  and  inanition,  and  good  feeding 
must  not  be  delayed  too  long.  The  nursing  woman,  moreover, 
needs  a  more  liberal  diet  than  other  patients.  Her  milk  contains  a 
large  percentage  of  proteid  and  fat,  and  she  also  loses  proteid  sub- 
stance to  a  greater  or  less  extent  through  the  lochia.  A  low  diet 
means  poor  milk,  for  it  diminishes  both  its  fats  and  proteids. 

Spiegelberg  says  :  "  It  is  a  bad  practice  to  allow  healthy  lying-in 
women  to  fast  long ;  they  need  to  be  well  fed,  and  if  the  appetite 
is  good  they  may  be  encouraged  to  eat."  If  they  are  well  nourished 
they  both  sleep  and  feel  better.  "Four  or  five  hours  after  con- 
finement the  patient  may  be  given  a  cup  of  hot  bouillon  or  chicken 
or  mutton  broth.  She  usually  does  not  care  for  meat  before  the 
second  or  third  day,  but  she  may  have  it  then.  Meanwhile  she  is 
allowed  broths  of  any  kind,  thickened  with  egg  or  rice,  milk,  tea, 
light  farinaceous  gruels  or  puddings,  soft-cooked  eggs,  toast,  milk 
toast,  custards."  Schroder  gives  meat  and  vegetables  within  a  day 
or  two  after  the  conclusion  of  labour.  Lusk  recommends  a  light  fluid 
or  semisolid  diet  for  the  first  three  days.  Then,  after  the  bowels 
have  moved  once  or  twice  and  the  appetite  returns,  he  gives  steak, 
chops,  a  piece  of  fowl  or  a  bird,  eggs,  and  cooked  fruits. 

Playfair  adopts  the  following  system  :  If  the  woman  is  confined 
in  the  early  morning  hours,  at  9  a.  m.  she  is  given  a  cup  of  tea  and 
a  piece  of  toast ;  at  i  p.  m.  a  light  lunch  of  some  form  of  predi- 
gested  meat  preparation  ;  at  5  p.  m.  tea  or  beef  tea,  and  at  7  p.  m.  a 
small  bit  of  chicken  with  bread  and  butter  or  milk  toast.  Tea 
again  at  9  p.  m.  He  discountenances  a  continued  use  of  gruels, 
"  slops,"  and  stimulants.  During  the  next  day  or  two  if  the  patient 
is  hungry,  he  allows  sweetbread,  chicken,  fish,  eggs,  and  milk. 

On  the  whole,  the  patient's  own  appetite  is  a  better  guide  for 
feeding  than  are  any  rules  as  to  the  exact  time  which  has  elapsed 
since  parturition.  She  should  not  be  urged  to  take  food,  unless 
greatly  exhausted,  and  the  stomach  must  not  be  overloaded ;  but  if 


7l6  RATIONS,   DIETARIES. 

hungry  after  the  establishment  of  the  milk  secretion  and  after  free 
action  of  the  bowels,  she  may  be  allowed  a  reasonable  quantity  and 
variety,  though  while  still  in  bed  she  needs  less  than  if  up  and 
about.  The  occurrence  of  fever  is  a  contraindication  for  giving 
much  proteid  food  except  milk,  but  extreme  exhaustion  without 
febrile  reaction  demands  it. 


SELECTION   OF  A  WET  NURSE. 

The  selection  of  a  wet  nurse  should  be  based  upon  the  following 
data : 

Her  own  general  health  and  digestion  must  be  good,  and  her 
bowels  not  habitually  constipated.  All  evidence  of  syphilis,  scrofula, 
tuberculosis,  or  other  disease  must  be  rigidly  excluded. 

Her  best  age  is  between  twenty-two  and  thirty  years,  and  she 
should  be  of  good  temperament  and  have  cleanly  habits. 

Her  period  of  lactation  should  not  be  too  widely  different  from 
the  age  of  the  infant  to  be  nursed.  As  lactation  proceeds  the  milk 
becomes  richer  in  both  cream  and  casein,  and  may  disagree  with  too 
young  a  stomach. 

The  breasts  should  be  firm,  and  the  nipples  fairly  prominent  and 
free  from  fissures.  Breasts  which  are  always  oozing  spontaneously 
are  by  no  means  always  the  best,  for  their  milk  is  soon  exhausted. 

The  nurse's  own  child,  if  living,  should  be  examined,  for  if  it  has 
been  nursing  at  the  breast  its  condition  is  an  even  better  index  of 
suitableness  of  the  mother's  milk  than  her  own  appearance. 

The  child  should  be  in  good  flesh  and  firm,  without  evidence  of 
gastric  catarrh,  fever,  or  indigestion,  and  of  good  development  for 
its  age. 

The  question  whether  it  is  possible  for  a  wet  nurse  to  transmit 
her  own  mental  and  physical  characteristics  to  the  child  at  her 
breast  has  given  rise  to  much  discussion,  but  there  is  no  more  reason 
why  she  should  transmit  an  evil  temper  through  the  food  she  gives 
than  that  a  cow  should  transmit  a  bland  one.  An  ill-tempered,  iras- 
cible wet  nurse  may  sometimes  give  milk  which  disagrees  with  the 
child's  stomach,  but  beyond  that  there  is  nothing  in  the  belief  that 
she  can  affect  it  mentally  or  morally  by  this  agency. 

The  milk  which  can  be  expressed  from  the  breast  should  have 
the  following  properties:  Reaction  alkaline,  color  an  opaque  blue- 
white,  specific  gravity  1.031,  taste  sweetish.  Examined  microscopic- 
ally, the  fat  corpuscles  should  abundantly  fill  the  field  and  be  of 
nearly  equal  size. 

Human  breast  milk  on  an  average  has  a  specific  gravity  of  1.031 
at  70°  F.,  but  it  varies  between  1.017  and  1.036  (Holt).  The  fat 
varies  less  than  the  sugar  and  proteids. 


DIET   OF   A   NURSING   MOTHER   OR   WET   NURSE. 


717 


If  the  specific  gravity  of  the  milk  is  high,  and  at  the  same  time 
the  percentage  of  fat  is  considerable,  the  gravity  must  be  due  to  a 
larger  quantity  of  proteids  than  usual,  because  fat  tends  to  lower  it. 
If  the  fat  percentage  is  small  and  the  specific  gravity  of  the  milk  is 
lew,  the  proteids  must  also  be  reduced.  Holt  furnishes  the  follow- 
ing convenient  table  for  determining  the  richness  of  human  milk  in 
fats  and  proteids,  which  gives  results  that  are  sufficient  for  practical 
purposes  in  examining  the  milk  of  a  wet  nurse  : 


Specific  gravity 
jo"  F. 

Cream — 24  hours. 

Proteids — (calculated). 

Normal  average .... 

1. 031 

7% 

1.5!^ 

Healthy  variations. . 

1.028 — 1.029 

8^—12^ 

Normal  (rich  milk). 

"               "         . . 

1.032— 1.033 

5%—  (>% 

"        (fair  milk). 

Unhealthy     " 

Below  1.028 

High  (above  10^). 

"        or  slightly  below. 

"           " 

Normal  (5^—10^). 

Low 

"           " 

Low  (below  5^). 

Very  low  (very  poor  milk). 

Above  1.033 

High. 

Very  high  (very  rich  milk). 

«          0 

Normal. 

High 

"          " 

Low. 

Normal  (or  nearly  so). 

To  calculate  the  actual  fat  from  the  cream  multiply  by  three 
fifths. 

In  examining  the  composition  of  the  milk  of  a  wet  nurse  it  is 
only  fair  to  the  nurse  to  remember  that,  like  cow's  milk,  her  own 
contains  less  fat  when  the  milk  is  first  drawn  than  after  the  breast 
has  been  nursed  for  a  few  moments. 

The  quantity  of  the  milk  may  be  best  estimated  by  weighing  the 
infant  immediately  before  and  after  suckling,  when  the  gain  should 
be  between  three  and  six  ounces. 


DIET  OF  A  NURSING  MOTHER  OR  WET  NURSE. 

The  diet  of  the  nursing  mother  or  wet  nurse  must  be  regulated, 
to  prevent  noxious  substances  from  passing  into  the  breast  milk  and 
to  keep  her  in  good  health,  so  that  she  does  not  suffer  from  constipa- 
tion, indigestion,  or  anaemia.  Her  weight  should  not  alter,  and  if 
she  has  menstruated  once  or  twice  the  milk  changes  and  may  dis- 
agree. 

If  milk  does  not  make  her  constipated  or  bilious  she  may  drink 
it  abundantly.  She  may  take  gruels  and  meat  broths,  and  she  should 
eat  simple  nourishing  food,  meat,  eggs,  vegetables,  and  fruits.  The 
latter,  even  if  sour,  do  not  react  unfavourably  upon  the  child,  pro- 
vided the  mother's  digestion  is  good,  and  they  serve  to  keep  the 
child's  bowels  active.  The  mother  should  forego  the  drinking  of 
much  tea  and  coffee.  Beer  and  wine  also  should  not  be  drunk  unless 
they  are  especially  prescribed  as  a  tonic.     Wet  nurses  often  demand 


7i3  •  RATIONS,   DIETARIES. 

beer,  ale,  or  porter  with  their  meals  if  they  have  been  accustomed  to 
it ;  but  the  popular  idea  that  such  beverages  are  especially  beneficial 
is  fallacious.  Malt  liquor  sometimes  causes  the  secretion  of  more 
milk,  because  more  fluid  is  drunk,  but  the  milk  is  no  better  for  it. 
A  reasonable  quantity  of  fluids  should  be  drunk,  however,  or  the 
secretion  of  milk  will  suffer.  The  fluid  may  be  in  the  form  of  plain 
or  effervescing  water,  milk,  soups,  etc. 

The  mother  or  wet  nurse  should  avoid  all  fatigue,  worry,  and 
emotional  excitement  of  any  kind,  which  may  inhibit  her  digestive 
functions,  and  should  take  daily  outdoor  exercise. 

On  the  whole,  the  best  indication  for  the  dietetic  treatment  of 
the  wet  nurse  is  the  study  of  the  condition  of  the  child's  digestion, 
bowels,  and  nutrition.  A  too  meagre  diet  for  the  nurse  is  soon  evi- 
dent in  lack  of  nutrition  and  development  of  the  infant. 

Drugs  in  Human  Milk. — Not  many  drugs  pass  unchanged  into 
the  milk  which  are  likely  to  poison  the  child  through  its  food,  but  there 
are  some  which  should  be  carefully  avoided  on  this  account.  Such 
are  belladonna,  opium,  morphine,  and  other  alkaloids  ;  iodine  and  its 
preparations  ;  mercury  and  its  salts  ;  salicylic  acid  (see  page  48). 

When,  for  any  reason,  it  becomes  necessary  to  discontinue  the 
nursing  and  to  stop  further  secretion  of  milk,  the  diet  should  at 
once  be  made  as  dry  as  possible,  and  a  minimum  quantity  only 
of  fluid  is  allowed. 


THE    FOOD    OF    INFANTS. 

Size  of  the  Infant  Stomach. — With  regard  to  infant  nursing, 
it  is  never  sufficient  to  give  general  directions  about  an  infant's 
food.  The  physician  should  supervise  the  exact  mode  of  its  prepara- 
tion, and  order  both  the  quantity  to  be  given  and  the  intervals  at 
which  it  is  to  be  given. 

Mothers  seldom  know  what  is  best  for  their  infants  in  these 
matters. 

It  is  therefore  well  to  explain  to  them  fully  the  facts  as  to  the 
proper  hours  for  feeding  and  the  amount  of  food  required,  and  also 
to  give  them  some  idea  of  the  size  of  the  infant  stomach,  for  many 
have  a  vague  idea  that  the  word  "  stomach  "  includes  almost  the  en- 
tire abdominal  cavity. 

Rotch  gives  the  following  table  of  capacities  of  infant  stomachs : 

1.  Premature  8  months'  infant 8  cubic  centimetres. 

2.  Infant  5  days  old 25-30     "  " 

3.  Infant  4  weeks  old 75      "  " 

4.  Infant  8       "        "    96     "  " 

5.  Infant  16     "        "    107     "  " 

6.  Infant  20     "        "    108      "  •* 


THE   FOOD   OF   INFANTS. 


719 


It  is  advisable  to  show  the  mother  or  nurse  an  empty  bottle  rep- 
resenting the  capacity  of  the  infant's  stomach,  in  order  to  impress 
upon  her  the  danger  of  overloading  it. 

Overfeeding. — It  is  sometimes  said  that  overfeeding  kills  more 
babies  than  starvation,  and  certainly  it  is  responsible  for  a  large 
proportion  of  the  ailments  of  early  infancy,  such  as  gastric  catarrh 
and  diarrhoea.  This  is  especially  true  in  summer,  when  the  fretful- 
ness  of  the  child,  which  is  often  mistaken  for  hunger,  may  be  due  to 
thirst,  the  external  temperature,  too  warm  clothing,  or  indigestion. 
At  such  times  Holt  advises  reducing  the  bulk  of  each  meal  by  one 
quarter  and  giving  the  infant  more  water  to  drink,  for,  as  he  says, 
infants,  like  adults,  require  less  food  in  excessively  hot  weather. 

It  is  difficult  to  impress  mothers  with  the  fact  that  milk  should 
never  be  given  to  soothe  a  baby's  fretfulness  merely,  and  "unme- 
thodical and  improper  feeding  is  quite  as  bad  as  feeding  with  im- 
proper aliments  "  (Adams). 

The  young  infant  secretes  no  ptyalin  to  digest  starch,  and  Biedert 
finds  that  the  infant  stomach  does  not  well  digest  albumin  when  its 
solution  is  stronger  than  i  per  cent. 

Methods  of  Feeding. 

Infants  may  be  given  their  food  in  one  of  four  ways :  I.  By 
mother's  milk.  II.  By  milk  from  a  wet  nurse.  III.  By  bottle  feed- 
ing. IV.  By  mixed'  feeding — i.  e.,  when  the  mother's  or  nurse's  milk 
is  supplemented  by  bottle  feeding. 

There  is  no  room  for  doubt  that  infants  brought  up  on  breast 
milk  are  stronger  and  better  able  to  remain  in  good  health  and  re- 
sist disease  than  those  who  are  hand  fed,  for  no  infant  food  has  ever 
been  devised  which  is  in  every  way  as  satisfactory  as  good  mother's 
milk. 

I.  AND  II.— feeding  by  the  mother  or  wet  nurse. 

Starr  advises  putting  the  infant  to  the  breast  as  early  as  six  or 
eight  hours  after  labour  is  completed,  which  is  good  for  both  mother 
and  child.  For  the  mother  it  improves  the  nipple,  stimulates  the 
true  milk  secretion,  and  reflexly  the  uterine  contractions;  for  the 
infant  it  is  also  desirable,  for  it  insures  the  ingestion  of  colostrum. 

Colostrum  constitutes  the  secretion  of  the  first  three  days.  This 
secretion  is  mildly  laxative,  and  it  cleanses  the  child's  alimentary 
canal  of  the  waste  matter  called  meconium,  which  is  found  within  it 
at  birth. 

Colostrum  contains  an  excess  of  albumin,  so  that  boiling  coag- 
ulates it.  It  also  has  large  corpuscles,  which  may  be  seen  with  the 
microscope  throughout  the  first  week  of  lactation,  gradually  lessen- 
ing in  number.  They  then  rapidly  disappear,  and  none  should  be 
48 


720  RATIONS,   DIETARIES. 

present  after  a  fortnight.  If  found  later,  the  milk  is  certain  to  dis- 
agree and  a  change  of  nurse  is  necessitated. 

Intervals  for  Feeding. — Infants  during  the  first  three  days 
should  be  nursed  only  four  or  five  times  a  day.  Water  may  be  given, 
but  no  bottle  food,  which  only  upsets  the  stomach  and  lessens  the" 
ability  to  suck.  After  this  period  once  every  two  hours  is  the  proper 
interval  for  suckling  for  the  first  six  weeks  or  two  months.  The 
child  should  be  nursed  at  this  interval  between  5  a.  m.  and  11  p.  m., 
with  one  feeding  only  in  the  middle  of  the  night.  If  absolute  regu- 
larity is  always  observed  in  the  hours  for  nursing,  the  child's  digest- 
ive organs  keep  in  much  better  condition,  it  sleeps  better,  and  is 
much  less  likely  to  be  overfed.  During  the  first  four  or  five  months 
of  life  an  infant  should  be  fed  once  during. the  night ;  after  that  it 
need  not  be  fed  between  10  p.  m.  and  7  a.  m.  When  a  year  old,  if 
strong  and  well,  it  need  not  be  fed  between  7  p.  m.  and  7  a.  m.  If 
fed  or  nursed  oftenerthan  this,  the  child  receives  too  much  food,  and 
digestion  and  rest  are  both  disturbed. 

Sometimes  an  infant  will  demand  milk  at  night  and  not  take  it  in 
the  daytime  as  well  as  it  should,  but  with  a  little  firmness  and  by 
starving  it  for  a  few  hours  until  it  is  really  hungry,  it  can  often  be 
trained  to  suckle  in  the  manner  which  experience  has  proved  is  best 
for  both  itself  and  its  mother. 

From  fifteen  to  twenty  minutes  is  sufficient  time  to  keep  the  child 
at  the  breast,  and  it  will  often  doze  off  to  sleep  after  nursing. 

As  the  child  grows  older  the  intervals  between  the  hours  of  nurs- 
ing are  to  be  prolonged,  in  accordance  with  the  tables  given  below 
(pages  727,  728),  and  the  child  may  be  allowed  to  remain  a  few 
moments  longer  at  the  breast. 

The  infant  while  sucking  should  always  be  held  in  a  comfortable 
position  with  the  nipple  within  easy  reach. 

After  a  three-hour  interval  for  feeding  has  been  reached,  it  may 
be  maintained  in  many  cases  until  lactation  is  completed,  but  after 
reaching  six  months  of  age  some  infants  do  better  with  a  three  and 
a  half  or  four  hours'  interval. 

Infants  born  with  a  cleft  lip  cannot  be  properly  nursed  at  the 
breast,  for  they  are  unable  to  make  the  necessary  vacuum  in  the 
mouth  to  draw  the  milk.  They  may  be  unable  to  take  the  bottle 
successfully,  and  must  then  be  fed  by  gavage  or  with  a  spoon. 

III.— FEEDING  BY  THE  BOTTLE. 
When  it  becomes  necessary  to  employ  artificial  feeding  there  are 
two  principles  upon  which  it  may  be  conducted.  The  first  and  most 
extensively  practised  is  to  endeavour  to  obtain  a  food  by  modify- 
ing cow's  milk,  which  corresponds  as  nearly  as  possible  to  the  com- 
position of  average  human  milk.     The  second  is  to  adapt  the  pre- 


THE   FOOD   OF   INFANTS.  721 

pared  milk  to  the  needs  of  each  particular  infant,  as  suggested  by 
the  state  of  its  digestive  organs  and  existing  nutrition  and  develop- 
ment. The  first  method  seeks  to  bring  the  child  up  to  the  standard 
of  the  milk,  the  second  to  bring  the  milk  to  the  standard  of  the 
child.  The  latter  has  been  newly  elaborated,  and  the  minute  details 
with  which  it  is  now  conducted  should  be  allowed  the  test  of  more 
extended  clinical  experience  than  has  been  yet  accumulated  before 
they  are  accepted  or  condemned.  This  system  of  "prescription 
writing  "  as  applied  to  milk  seems,  in  some  cases  of  severe  illness 
and  great  impairment  of  digestion,  more  rational  than  the  older 
method,  but  it  presupposes  much  experience  and  care  on  the  part 
of  the  physician. 

Due  regard  must  be  had,  of  course,  for  the  circumstances  of  those 
for  whom  an  especially  modified  diet  is  ordered.  For  the  very  poor, 
milk  is  a  serious  item  of  expense,  and  cream  and  sugar  may  be  out 
of  the  question.  Condensed  milk  is  usually  cheaper  in  large  cities 
than  fresh  cow's  milk,  for  less  care  and  expense  is  involved  in  its 
transportation,  and  it  is  accordingly  much  used  by  the  poor.  More- 
over, in  hot  weather  it  keeps  without  ice,  but  for  reasons  given  else- 
where (page  8i)  it  is  never  to  be  preferred  when  good  fresh  cow's 
milk  is  obtainable. 

Cow's  milk  contains  approximately  half  the  quantity  of  sugar 
present  in  human  milk. 

Leeds  says  that  the  curd  derivable  from  human  milk  is  only  one 
fifth  as  much  as  that  of  cow's  milk,  and  there  are  other  striking  differ- 
ences in  regard  to  the  quantity  of  casein  precipitable  by  acid,  as 
compared  with  the  non-coagulable  ingredients  of  both  forms  of 
milk. 

For  this  reason  it  must  be  diluted  for  very  young  infants  with 
two  parts  of  water,  in  order  to  bring  the  casein  nearer  to  the  right 
proportion ;  but  the  addition  of  water  reduces  the  percentage  of  fat 
and  of  sugar. 

E.scherich  has  shown  that  the  infant  fed  upon  diluted  cow's  milk 
has  to  take  much  more  fluid  than  when  nursed  by  breast  milk  to  get 
the  same  quantity  of  nutriment,  with  consequent  distention  and  pos- 
sible enfeeblement  of  the  stomach. 

The  disproportion  of  fat  may  be  counterbalanced  by  using  "top 
milk  "— i.  e.,  the  upper  layer  which  forms  after  the  milk  has  stood  for 
about  eight  hours,  and  which  contains  most  of  the  cream.  Milk  sugar 
is  then  to  be  added  in  the  proportion  of  one  heaping  teaspoonful  to 
four  ounces  of  the  diluted  milk.  If  cane  sugar  is  used,  which  is 
less  desirable,  as  it  is  more  apt  to  ferment,  only  one  teaspoonful  to 
every  six  ounces  is  necessary. 

From  a  quart  of  ordinary  milk  six  ounces  of  top  milk  may  be 
skimmed,  seven  ounces  from  rich,  and  five  from  poor  milk.     In  lieu 


722 


RATIONS,   DIETARIES. 


of  top  milk  a  mixture  of  equal  parts  of  cream  and  of  ordinary  milk 
should  be  used  (Holt). 

When  the  milk  causes  dyspepsia,  and  large  curds  are  vomited, 
it  is  well  to  substitute  barley  water  for  plain  water  in  the  same  pro-^ 
portion. 

If  pearl  barley  is  used  it  should  be  boiled  a  long  time — for  six  or 
eight  hours — the  water  being  replaced  as  it  evaporates.  The  pro- 
portion usually  employed  is  two  tablespoonfuls  of  barley  to  the  quart 
of  water.  After  careful  straining  through  a  linen  cloth,  a  pinch  of 
salt  is  added,  and  when  cool  the  fluid  is  ready  for  use.  Instead  of 
pearl  barley,  one  of  the  barley  flours  may  be  employed.  This 
answers  the  purpose  as  well,  and  has  the  advantage  of  requiring 
much  less  time,  boiling  for  haff  an  hour  being  sufficient. 

Holt  gives  the  following  formulae  for  an  infant  two  months  old 
receiving  twenty-four  ounces  a  day  : 

Top  milk 8  ounces. 

Barley  water i6      " 

Milk  sugar 6  heaping  teaspoonfuls,  or 

Cane  sugar 4        "  " 

The  quantity  is  to  be  slightly  increased,  but  the  proportion  may 
remain  the  same  until  the  seventh  or  eighth  month,  when  the  mix- 
ture should  be  changed  to — 

Top  milk .■ 19  ounces. 

Barley  water 19       " 

Milk  sugar 9  teaspoonfuls,  or 

Cane  sugar '5  " 

In  answer  to  the  question,  "  Can  a  child  one  year  old  take  plain 
cow's  milk  ?  "  Holt  says:  "  Many  children  can,  but  the  majority  do 
better  when  the  milk  is  modified  by  the  addition  of  cream  and  water, 
or  by  the  use  of  diluted  top  milk.  After  standing  six  hours  six 
ounces  should  be  taken  off  from  the  top  of  the  milk  bottle  and  ten 
ounces  more  should  then  be  poured  off  and  the  two  mixed.  This 
may  be  diluted  with  an  equal  quantity  of  water  or  barley  water." 

It  is  generally  conceded  that  fresh  raw  cow's  milk  derived  from 
a  healthy  cow,  and  carefully  kept  from  germ  contamination,  is  a 
more  wholesome  food  for  babies  than  milk  which  is  either  boiled, 
sterilised,  Pasteurised,  or  peptonised.  But  in  cities  always,  and 
everywhere  in  summer,  it  is  difficult  or  impossible  to  obtain  such 
milk,  and  one  or  other  of  the  means  of  disinfection  becomes  im- 
perative. 

The  heat  required  for  sterilisation  in  some  manner  destroys  the 
vital  properties  of  nuclein  of  the  milk  (Starr). 

According  to  the  observations  of  Toch  (Archiv  f.  Kinderheilkunde, 
xvi)  on  the  stomach  contents,  the  peptonising  of  milk  for  infants 


THE   FOOD   OF   INFANTS. 


723 


is  useless,  for  he  has  demonstrated  the  presence  of  pepsin  in  the 
gastric  juice  of  infants,  even  when  having  gastric  catarrh. 

Peptonised  milk  is  used  much  less  for  infant  feeding  than  for- 
merly, for  it  has  been  found  that  they  do  not  thrive  if  continuously 
fed  upon  it. 

Care  of  the  Milk. — In  order  to  keep  milk  fresh  and  pure  for 
infant  use  in  hot  weather  it  should  be  at  once  artificially  cooled,  and 
if  intended  for  city  consumption,  during  transportation  both  car  and 
delivery  wagon  should  be  supplied  with  ice,  so  that  the  milk  temper- 
ature never  rises  above  50°  F.  The  milk  when  received  at  the  deal- 
er's should  also  be  kept  in  refrigerators,  for  it  is  exceedingly  im- 
portant that  it  should  not  become  lukewarm  even  temporarily.  It 
would  be  an  undoubted  advantage  to  have  the  whole  system  of  milk 
supply  under  proper  inspection  and  licensing.  The  cows  when 
stabled  should  be  kept  in  clean,  well-ventilated  quarters,  and  should 
always  have  the  udders  washed  before  milking.  Every  receptacle 
used  for  holding  the  milk  should  be  thoroughly  scoured  with  boiling 
water  each  day,  but  after  first  rinsing  with  cold  water.  If  this  pro- 
cess is  reversed,  particles  of  scalded  milk  may  cling  to  the  pail  or 
can  and  give  rise  to  subsequent  fermentation.  Milk  should  never  be 
allowed  to  stand  about  in  uncovered  vessels,  especially  in  a  bath 
room,  near  an  open  sewer  pipe  or  drain,  or  in  a  damp  cellar. 

When  given  to  the  infant  the  milk,  as  well  as  all  infant  food, 
should  be  moderately  warmed  to  approximate  its  body  temperature 

(99°  F.). 

When  the  milk  temporarily  disagrees  it  becomes  necessary  to  sub- 
stitute for  it  some  other  form  of  food.  Useful  formulae  for  this 
purpose  are  given  by  Starr  as  follows : 

Substitutes  for  Milk  in  Infant  Feeding  (Starr). 

Veal  broth  (i  lb.  of  meat  to  the  pint) f  5  Jss. 

Barley  water f  §  jss. 

Mix. 

j;   ,  y*  ) each,  one  and  a  half  ounce. 

Barley  water,  \ 

Milk  sugar half  a  drachm. 

Give  one  portion  at  two  months. 

Raw  beef  juice  (one  teaspoonful  every  two  hours)  will  "be  re- 
tained when  everything  else  is  rejected." 

Both  barley  water  and  lime  water  are  sometimes  added  when 
temporary  looseness  of  the  bowels  occurs. 

In  using  lime  water  (carbonate  of  lime)  as  a  diluent  of  cow's  milk 
in  infant  feeding,  it  should  be  remembered  that  in  the  latter  the 
phosphate  of  lime  is  four  times  greater  in  quantity  than  in  human 
milk  (Leeds),  and  it  is  of  questionable  utility  to  continue  the  practice 
beyond  the  requirements  of  a  temporary  fit  of  indigestion. 


724 


RATIONS,  DIETARIES. 


Many  persons  suppose  that  the  milk  from  a  single  cow  is  to  be 
preferred  to  the  mixed  milk  of  several  animals,  and  formerly  some 
dairies  used  to  supply  such  milk  in  separate  bottles.  It  has  been 
proved,  however,  that  there  is  less  variation  in  the  quality  of  mixed 
milk,  and  t,he  infant  is  not  so  apt  to  become  dyspeptic  while  tak- 
ing it. 

The  milk  of  fancy  breeds  of  cows,  such  as  that  of  thoroughbred 
Alderneys  or  Durhams,  is  often  too  rich  both  for  infants  and  invalids, 

IV.— MIXED   FEEDING. 

There  is  no  harm  whatever  in  partly  feeding  infants  with  the 
bottle  who  are  at  the  same  time  being  nursed.  If  the  mother  is  suf- 
fering from  want  of  sleep  she  will  be  of  more  value  to  her  infant  if 
allowed  to  sleep  at  night  while  her  child  is  hand-fed  once  or  twice. 
When  the  breast  milk  is  insufficient  or  poor  in  quality  the  child  must 
be  fed  by  hand  several  times  a  day  in  addition  to  nursing.  A  hun- 
gry, ill-nourished  child  cries  continuously  in  a  fretful  manner  and 
nurses  irregularly,  either  taking  the  breast  too  long  and  eagerly  or 
stopping  too  soon  if  it  cannot  obtain  the  milk  without  much  effort. 
The  sleep  is  fitful,  the  abdomen  is  tender  and  usually  distended  with 
gas.  There  may  be  vomiting,  and  the  stools  are  malodorous  and 
contain  milk  curds. 

Sometimes  such  babies  may  be  given  the  bottle  for  the  greater 
part  of  their  food  for  a  few  days,  until  the  mother's  milk  is  found  to 
agree  with  them  better,  and  thus  the  necessity  for  absolute  weaning 
may  be  postponed. 

Infants  who  are  brought  up  to  take  the  bottle  once  or  twice  at 
night,  being  nursed  at  the  breast  in  the  daytime,  are  usually  more 
easily  weaned  when  the  period  for  entire  hand-feeding  arrives. 

When  a  mother  who  has  abundant  miik  supply  is  obliged  to  be 
temporarily  absent  from  her  infant  beyond  the  period  when  a  meal 
is  due,  she  may  beforehand  express  into  a  clean  glass  a  little  milk 
which  may  be  kept  and  fed  to  the  child  with  a  teaspoon  while  the 
mother  is  away. 

Weaning. 

The  period  for  weaning  varies  considerably,  according  to  the 
health  and  vigour  of  both  mother  and  infant.  As  a  rule,  it  should 
be  between  the  tenth  and  eighteenth  month,  ordinarily  not  before  the 
tenth  or  twelfth  month  has  been  passed.  Many  infants  are  nursed 
for  fifteen  months,  but  after,  if  not  before  the  eighteenth  month  the 
mother's  milk  deteriorates,  and  the  child's  needs  will  be  better  met 
by  bottle  feeding.  There  can  be  no  fixed  rule  about  this,  however, 
and  much  depends  upon  the  nationality  and  social  position  of  the 
mother.  The  poor,  for  reasons  of  economy,  sometimes  nurse  their 
children   longer   than  is  good   for    them,  and   many   foreigners   in 


THE   FOOD   OF   INFANTS. 


725 


this  country  seem  able  to  nurse  their  infants  longer  than  native 
Americans. 

The  eruption  of  the  eight  incisor  teeth,  which  should  be  com- 
plete by  the  end  of  the  first  year,  is  often  regarded  as  an  indication 
for  weaning.  At  this  time  the  digestive  organs  become  stronger, 
the  saliva  becomes  more  abundant,  and  the  appearance  of  the  an- 
terior molar  teeth  is  a  sign  that  the  child  is  gradually  preparing  for 
solid  food. 

Usually,  even  though  the  anterior  molar  teeth  are  cut,  the  child, 
if  weaned,  should  still  be  fed  chiefly  upon  milk  until  the  eighteenth 
month.  It  is  best  not  to  wean  a  child  during  very  hot  weather,  but 
when  this  is  imperative  milk  only  should  be  given,  otherw'se  a  small 
quantity  of  beef  juice,  egg,  etc.,  may  be  allowed  by  degrees. 

An  infant  may  be  weaned  at  any  time,  and  occasion  may  require 
its  being  done  suddenly,  but  ordinarily  the  process  should  occupy  at 
least  one  or  two  months.  When  the  child  is  nine  or  ten  months  of 
age  the  bottle  may  be  given  once  a  day  in  place  of  the  breast ;  later 
two  or  three  times,  and  so  on,  until  at  the  end  of  a  year  the  weaning 
is  completed.  This,  however,  is  a  very  general  rule,  subject  to 
modifications  necessitated  by  the  ill  health  of  mother  or  child,  or  by 
hot  weather,  etc. 

The  circumstances  which  necessitate  earlier  weaning  than  the 
period  after  the  twelfth  month  may  be  due  to  the  condition  of  the 
infant,  who  may  have  malformation  of  the  mouth  or  be  congenitally 
too  feeble  to  suckle,  or  rendered  so  by  some  disease,  such  as  rickets 
or  hereditary  syphilis,  or  the  condition  of  the  mother  may  be  at 
fault,  either  from  constitutional  disease,  such  as  tuberculosis  or 
syphilis,  from  local  disease,  abscess,  or  malformation  of  the  nipples, 
from  insufificient  or  poor  milk,  or  from  the  recurrence  of  menstrua- 
tion or  pregnancy. 

If  an  infant  be  nursed  after  the  mother's  milk  has  grown  poor  in 
quality  it  may  acquire  rickets  and  digestive  disorders. 

The  following  directions  for  weaning  an  infant  from  the  bottle 
and  for  feeding  during  the  second  year  are  concisely  given  by  Holt 
in  his  admirable  brochure  on  The  Care  and  Feeding  of  Infants  (1894). 
They  summarise  concisely  a  very  large  experience  : 

"  At  ten  months  the  bottle  or  breast  milk  may  be  supplemented 
by  a  little  beef  juice  or  a  portion  of  a  soft-boiled  tgg.  If  the  bottle 
is  given,  arrowroot  or  farina  may  be  added  to  one  feeding  each 
day.  .  .  . 

"  A  child  should  always  be  weaned  as  early  as  eighteen  or  twenty 
months,  but  it  can  be  easily  done  at  twelve  or  fifteen  months.  .  .  . 
During  the  second  year  a  healthy  child  never  requires  more  than 
five,  and  some  do  better  with  four,  meals  during  the  latter  half  of 
the  year.  ... 


-26  RATIONS.   DIETARIES. 

"  If  five  meals  are  given,  the  best  hours  are  7  a.  m.,  10  a.  m., 
I  p.  M.,  4  p.  M.,  7  p.  M.,  with  nothing  whatever  during  the  night.  It 
is  better  to  make  the  10  a.  m.  and  4  p.  m.  meals  rather  smaller  than 
the  others." 

Starr  gives  the  following  mixture  for  use  in  commencing  weaning 
at  the  tenth  month  : 

Weaning  Mixture  at  Ten  Months  (Starr). 

Cream f  5  ss. 

Milk f  §  iv. 

Sugar  of  milk f  j. 

Water f  §  jss. 

* 

If  disorder  of  digestion  occurs  return  to  the  breast. 

Dencke,  of  Jena,  publishes  the  following  table  (Centralbl.  fiir 
Gynakol.,  vol.  xv)  as  a  result  of  feeding  normal  infants  on  Swiss 
milk  for  the  first  nine  days  : 


Daily  amount  consumed,  in  ounces  . 
Relation   of    this   amount    to  body 

weight,  in  percentage 

Quantity  per  meal,  in  ounces..  ..*... 
Number  of  meals /^r  diem 


DAYS 

I. 

2. 

3- 

4- 

5- 

6. 

7- 

8. 

1-5 

4.6 

6.5 

9.0 

II. 8 

12.5 

13.0 

14. 1 

r.4 

4-5 

6.4 

8.7 

"•3 

II. 7 

12.3 

13.2 

0.65 

0.79 

1.06 

1-37 

1-75 

I-.";? 

2.06 

2.1 

2.1 

5-7 

6.2 

6.7 

7.0 

6.8 

6.3 

6.8 

14-5 

13-9 
2.2 
6.7 


Holt  presents  the  following  table,  based  on  the  measurement  of 
forty  infant  stomachs  and  the  weighing  of  infants  immediately  be- 
fore and  after  nursing.  The  table  gives  the  averages  computed 
from  such  data,  but  the  robust  will  require  a  little  more,  and  the 
feeble  will  take  less  food.     The  measurements  are  in  ounces  : 


Age. 

Quantity  suckled  at  one  feeding. 

Number  of  feedings. 

Total  daily  amount. 

2  weeks 

2 

3 
4 

5 
5i-6 
7-7* 
8-9 

8 
8 

7 
6 
6 

5 
5 

16 

I  month 

24 

28 

2  months 

4  months 

30 
33-36 
35-38 
40-45 

6  months 

9  months 

12  months 

The  average  weight  of  the  child  at  birth  may  be  given  as  three 
kilogrammes  (Widerhofer).  If  it  weighs  less  than  two  kilogrammes 
it  is  usually  very  feeble. 

After  the  twelfth  month  three  pints  is  the  limit  of  digestive 
capacity  for  food  for  the  stomach  for  one  day.  If  the  child  seems 
to  need  more  nourishment,  the  strength  of  the  food,  but  not  its  bulk, 
may  be  increased. 


THE   FOOD   OF   INFANTS. 


727 


The  following  table  is  from  Rotch's  Pediatrics  (page  266) : 
Table  showing  Management  of  the  Food  and  Increase  in    Weight  of  a 
Healthy  Infant  {Case  g2)  during  the  First  Fifty-two  Weeks  of  its  Life. 


Date. 

Weeks 
of  life. 

Weight. 

Amount  at 
each  feeding. 

Fat. 

Sugar. 

Pro- 
teids. 

Lime- 
water. 

Grms. 

Lbs. 

Oz. 

C.c. 

Oz. 

Nov.      I 

I 

3,180 

7 

I 

8 

2 

3,180 

7 

I 

60 

2 

2.00 

5.00 

1. 00 

5.00 

"      15 

3 

3,180 

7 

I 

60 

2 

4.00 

7.00 

1. 00 

"      22 

4 

3.430 

7 

10 

90 

3 

4.00 

7.00 

1. 00 

"      29 

5 

3,520 

7 

14 

75 

2i 

300 

7.00 

1. 00 

Dec.      6 

6 

3,730 

8 

5 

3-00 

6.00 

1. 00 

"      13 

7 

3,980 

8 

14 

3.00 

7  00 

1. 00 

"      20 

8 

4,160 

9 

4 

90 

3 

4.00 

7.00 

1. 00 

10.00 

"      27 

•        9 

4,340 

9 

10 

105 

3i 

4.00 

7.00 

1.25 

5.00 

Jan.       3 

.      10 

4,590 

10 

4 

4.00 

7.00 

1.50 

10 

II 

4,870 

10 

14 

"        17 

12 

5,060 

II 

4 

"       24 

.      13 

5,270 

II 

12 

"       31 

.      14 

5,560 

12 

6 

Feb.      7 

•      15 

5,870 

13 

I 

120 

4 

.... 

.... 

.... 

12.50 

"       14 

.      16 

6,070 

13 

8 

135 

4i 

10.00 

"      21 

.      17 

6,300 

14 

I 

5.00 

"       28 

.      18 

6,370 

14 

4 

March  7 

.      19 

6,510 

14 

8 

"     14 

20 

6,650 

14 

13 

150 

5 

4.00 

7.00 

2.00 

"     21 

21 

6,920 

15 

7 

"     28 

22 

6,980 

15 

9 

April     4 

.      23 

7,150 

15 

15 

"      II 

.      24 

7,240 

16 

2 

"      18 

.      25 

7,560 

16 

14 

"      25 

.      26 

7,600 

16 

15 

May      2 

.      27 

7,800 

17 

6 

"        9 

.      28 

7,730 

17 

4 

"       16 

.      29 

7,840 

17 

8 

"      23 

.      30 

8,070 

18 

180 

6 

"       30 

.      31 

8,160 

18 

3 

June     6 

.      32 

8,190 

18 

4 

"       13 

33 

8,490 

18 

15 

195 

6i 

4.00 

7.00 

a.  50 

"      20 

•      34 

8,470 

18 

14 

"       27 

.      35 

8,700 

19 

6 

July      4 

36 

8,762 

19 

8 

"      II 

.      37 

8,824 

19 

II 

"      18 

.      38 

8,950 

19 

14 

"      25 

•      39 

8,970 

20 

Aug.      I 

.      40 

8,980 

20 

8 

41 

9,060 

20 

3 

"       15 

.      42 

9,140 

20 

6 

"       22 

•      43 

9340 

20 

13 

"      29 

.      44 

9,170 

20 

7 

Sept.     5 

•      45 

9,290 

20 

II 

"      12 

.      46 

9,340 

20 

13 

"       19. 

•      47 

9,470 

21 

2 

"      26. 

.      48 

9,640 

21 

9 

Oct.      3. 

•      49 

9,630 

21 

7 

"       10 

.      50 

9,740 

21 

10 

4.00 

6.00 

3.00 

"       17. 

•      51 

9,870 

22 

Whole  milk. 

"       24 

.      52 

9,890 

22 

I 

•• 

Whole  milk  a 

nd  oat 

jelly. 

The  whole  heated  throughout  the  year  at  75'  C.  (167°  F.)." 


728 


RATIONS,   DIETARIES. 


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THE    FOOD   OF   INFANTS. 


729 


Holfs  '•  Schedule  for  Feeding  an  Average  Child  in  Health  "  for  the  First 

Year. 


1  week 

2  to  3  weeks 

4  weeks. . . . 
6      "     .... 

3  months . . . 

5  "       .•• 

6  "       ... 
9       "       ... 

12       "       ... 


to  6  A.  M. 


10 

2 

hours. 

10 

2 

9 

2 

8 

2i 

7 

3 

6 

3 

6 

3 

5 

3 

5 

3 

Quantity  for 
each  meal. 


I  OZ. 

li  " 

2\  " 

3  " 

4  " 
5i  " 
6  " 

1\  " 


Quantity  for 
24  hours. 


10  OZ 

15  ' 

20  ' 

24  ' 

28  ' 

33  ' 

36  ' 

37i  ' 
40 


Christie's  Table  for  Infant  Feeding. 


Age. 


1st  week 

2d  to  4th  week.. . 
2d  to  3d  month . . 
3d  to  4th  month  , 
4th  to  5th  month 

6th  month 

8th  month 

loth  month , 


Number  of  feed-j  Amount  of  food  Total  amount  ia 
mgs  in  24  hours  at  each  feeding.!       24  hours. 


10  OZ. 
I3i  OZ. 
18  OZ. 
24  OZ. 
24-27  OZ. 
30  OZ. 
36  OZ. 
40  OZ. 


The  foregoing  tables  differ  only  in  a  few  unimportant  details — 
less,  in  fact,  than  the  digestive  powers  of  infants  differ  from  each 
other. 

Artificial  Infant  Foods. 

Very  young  infants  fed  upon  "proprietary  "  or  "prepared  "  baby 
foods,  to  the  greater  or  less  exclusion  of  mother's  or  good  cow's 
milk,  soon  become  rhachitic  or  scrofulous.  Wiederhofer  says  that 
"  the  numerous  infant  foods,  although  much  bepuffed,  are  of  no 
value  whatever."  This  is  certainly  true  of  all  non-malted  amyla- 
.ceous  foods.  The  common  fault  of  nearly  all  such  preparations  is  that 
they  contain  too  much  sugar  or  starch  and  too  little  fat^which 
latter  is  very  difficult  to  preserve  without  becoming  rancid.  For 
example : 

Prof.  Leeds  says  that  Mellin's  food  has  only  0.15  part  fat  in 
144.74,  and  Nestle's  food  only  1.91  part  in  139.69,  but  human  milk 
has  3.90  per  cent  and  cow's  has  3.66  per  cent. 

Two  extreme  conditions  are  seen  in  such  infants — those  who  are 
emaciated  and  marasmic,  and  those  who  are  stout  and  apparently 
robust,  but  whose  strength  and  power  of  resistance  to  disease  is  very 
deceptive.  As  described  by  Holt :  "  When  children  are  fed  upon 
foods  lacking  in  fat,  the  teeth  come  late,  the  bones  are  soft,  the  mus- 
cles flabby,"  whereas  "children  fed  upon  foods  containing  too  much 


730 


RATIONS,   DIETARIES. 


sugar  are  frequently  very  fat,  but  their  flesh  is  very  soft,  they  walk 
late,  and  they  perspire  readily  about  the  head  and  neck."  They  pre- 
sent a  variety  of  rhachitic  deformities,  and  are  subject  to  catarrhal 
and  other  diseases.  Such  foods  should  never  be  fed  to  young  in-v 
fants  unless  under  a  physician's  direction.  For  the  further  discus- 
sion of  this  topic  the  reader  is  referred  to  the  section  upon  Pre- 
digested  Foods,  page  131. 

Another  objection  to  feeding  infants  with  starchy  food,  even 
when  partially  converted  by  diastase  into  dextrin  and  maltose,  is 
that  the  final  products  are  unlike  the  carbohydrate  of  normal  milk 
(lactose),  and  it  is  doubtful  whether  they  are  as  readily  assimilated 
and  as  useful  in  the  obscure  metabolic  processes  of  infant  growth. 

Predigested  proteid  foods,  such  as  somatose  and  various  forms  of 
meat  extracts,  albumoses,  etc.,  are  sometimes  used  to  re  enforce  the 
milk  of  very  young  infants  by  addition  to  it.  This  is  a  mistake,  for 
the  cow's  milk  is  already  too  rich  in  proteids.  If  temporary  indiges- 
tion requires  their  use,  they  should  be  substituted  for  milk,  and  not 
given  with  the  idea  of  re-enforcing  it. 

Infant  Stools. — The  stools  of  the  infant  should  be  observed 
from  time  to  time  in  order  to  ascertain  whether  the  milk  is  being 
properly  digested. 

The  stools  of  an  infant  fed  exclusively  on  milk  should  number 
two  (or  only  one)  a  day,  and  be  of  uniform  soft  consistence,  smooth, 
of  inoffensive  odour,  and  of  a  gamboge-yellow  colour.  If  meat  juice 
or  meat  broth  of  any  kind  is  given,  the  stools  usually  become  darker. 
If  too  much  is  given  they  are  apt  to  be  acid,  malodorous,  very  dark 
brown,  and  diarrhoeal. 

Abnormal  appearances  of  the  stools  will  be  found  described  in 
cunnection  with  the  dietetic  treatment  of  infantile  diarrhoea  (page 
532).  When  farinaceous  or  any  amylaceous  food  is  being  given,  it 
is  well  to  test  the  stools  with  a  few  drops  of  tincture  of  iodine  which 
imparts  a  purple  colour  to  any  particles  of  undigested  starch  which 
they  may  contain. 

Nursing  Bottles. — Ever  since  the  influence  of  bacteria  upon 
the  fermentation  of  milk  has  been  established  the  necessity  for  ob- 
serving carefully  the  most  minute  details  for  cleansing  all  the  in- 
fant's utensils  has  been  apparent. 

The  necessity  for  use  of  the  bottle  for  feeding  is  always  to  be 
regretted  on  account  of  the  difficulty  of  keeping  the  milk  from 
bacterial  infection.  Adams  says :  "  One  of  the  greatest  nuisances 
in  infantile  life  is  the  popular  feeding  bottle.  It  probably  causes 
more  intestinal  diseases  in  the  infant  under  two  years  of  age  than 
any  other  article." 

The  use  of  nursing  bottles  with  long  rubber  tubing  is  to  be  un- 
hesitatingly  condemned,  although  it  saves  trouble  in  holding  the 


THE    FOOD   OF   INFANTS. 


731 


bottle.  It  is  impossible  to  keep  the  tubing  sterile.  The  bottle 
should  be  of  pure  glass,  white,  of  half-pint  capacity,  with  a  wide 
mouth  and  a  sloping  neck,  and  never  with  a  shoulder,  which  pre- 
vents cleaning  every  part  of  the  interior  with  a  sterilised  cotton 
swab. 

A  measure  of  ounces  should  be  blown  in  the  side,  and  it  should 
be  fitted  with  a  short  black  rubber  nipple,  which  can  be  removed 
and  turned  inside  out  for  thorough  cleansing.  This  short  nipple  has 
the  further  advantage  that  the  child  is  less  apt  to  be  left  by  the 
nurse  alone  with  the  bottle.  The  latter  is  a  slovenly  way  to  feed  an 
infant,  and  should  be  discountenanced,  for  the  child  gets  its  milk 
with  periods  of  delay  and  irregularity.  The  bottle  may  slip  out  of 
reach,  or  after  it  is  empty  the  child  keeps  on  sucking  or  draws  in 
air,  and  obtains  the  milk  at  uneven  temperatures,  or  sometimes  the 
child  goes  to  sleep  with  the  nipple  in  its  mouth,  and,  awaking,  it 
finishes  the  bottle.  "  The  sucking  power  of  the  child  is  to  a  great 
extent  produced  by  the. muscles  at  the  posterior  portion  of  the 
mouth ;  if  this  action  is  carried  on  to  a  great  extent  it  has  a  ten- 
dency to  contract  the  width  of  the  mouth  and  cause  protrusion  of 
the  teeth"  (Cryer).  For  these  reasons  the  nurse  should  always  con- 
tinue holding  the  bottle  in  a  comfortable  position  for  the  child  until 
it  has  taken  its  portion.  This  usually  requires  a  few  minutes  less 
time  than  is  occupied  in  nursing  at  the  breast.  The  usual  time  is 
not  above  ten  minutes  (Dencke).  Any  residue  in  the  bottle  should 
be  at  once  thrown  away,  and  not  warmed  over  for  a  second  feeding. 

For  washing  the  milk  bottles  a  solution  of  sodium  bicarbonate  or 
salicylate,  a  teaspoonful  to  the  pint,  should  be  first  used,  after  which 
they  must  be  thoroughly  scalded  in  boiling  water.  If  fitted  with  a 
plug  of  sterilised  baked  absorbent  cotton  they  will  remain  sterile 
until  ready  for  use. 

When  from  six  to  eight  teeth  have  appeared  the  bottle  can  usu- 
ally be  discarded. 

Care  of  the  Infant's  Mouth.— Cryer  says  that  mothers  or 
nurses  in  caring  for  the  infant  "will  give  attention  to  dirty  hands  or 
face  and  bathe  the  body  daily,  but  how  few  keep  the  mouth  as  clean. 
The  teeth  should  be  gently  and  thoroughly  brushed  with  a  small 
soft  tooth  brush  as  soon  as  they  make  their  appearance.  .  .  .  Fer- 
mentation of  residual  portions  of  milk  remaining  in  the  mouth  of 
the  infant  after  feeding  is  a  prolific  source  of  gastric  curd,  intesti- 
nal irritation,  giving  rise  to  colic  and  diarrhoea.  The  mouth  of  the 
child  should  therefore  be  kept  carefully  cleansed,  and  before  each 
feeding  be  washed  out  with  a  solution  of  boric  acid  in  distilled  water 
applied  on  a  soft  linen  rag." 

Weighing  of  Infants.— The  systematic  weighing  of  infants  at 
least  once  a  week  is  a  very  useful  indication  of  the  progress  in  nu- 


732 


RATIONS,   DIETARIES. 


trition  and  growth  which    they  are  making,  and  it  should  not  be" 
neglected. 

Budin  has  recently  reported  some  interesting  experiments  with 
three  classes  of  infants — namely,  (i)  suckled,  (2)  partly  suckled, 
partly  artificially  fed,  (3)  artificially  fed.  During  the  first  fortnight 
of  life  he  found  that  the  gain  in  weight  was  considerably  more  rapid 
with  suckled  infants,  but  during  the  first  year  of  life  the  infant  will 
gain  as  much  weight  if  fed  upon  cow's  milk  as  if  suckled.  Roughly 
speaking,  the  infant's  weight  should  be  doubled  in  the  first  five 
months  of  life  and  trebled  in  the  first  year. 

Premature  Infants. — .The  feeding  of  premature  infants  de- 
mands unusual  care.  Their  bodies  are  small ;  their  vitality  is  low  ; 
their  digestion  is  feeble,  and  their  rate  of  heat  loss  is  rapid.  They 
are  sometimes  advantageously  reared  in  incubators.  They  are  often 
too  weak  to  suckle  or  even  to  take  the  bottle  unless  they  are  very 
carefully  hand-fed  so  as  to  obtain  the  milk  without  effort.  It  may 
be  best  to  feed  them  by  gavage.  This  method  takes  less  time  than 
any  other.  A  small,  feeble,  puny  infant  at  nine  months  of  age  may 
not  take  as  much  as  ten  ounces  of  milk  a  day,  and  yet  keep  alive. 
Such  a  baby  must  be  fed  at  shorter  intervals  than  the  rule  allows  for 
well-developed  infants  at  the  same  age.  A  two-hour  interval  will 
often  be  best. 

FOOD  FOR  YOUNG  CHILDREN. 

The  infant,  although  weaned,  should  receive  all  its  food  from 
the  bottle  until  at  least  the  twelfth  month,  and  then  very  gradually 
a  few  other  articles  than  milk  or  beef  juice  may  be  added. 

Children  often  do  best,  however,  upon  a  milk  diet  up  to  the  end 
of  the  second  year. 

"  Towards  the  end  of  the  second  year  all  the  milk  teeth  have 
cut  through,  and  the  digestive  functions  have  greatly  increased  in 
power.  The  lower  maxilla  becomes  stronger,  the  muscles  of  mastica- 
tion more  powerful,  the  cavity  of  the  mouth  larger,  the  lips  more 
fleshy,  the  oesophagus  wider;  the  salivary  glands  are  better  de- 
veloped, and  secrete  a  larger  quantity  of  saliva  ;  the  shape  of  the 
stomach  changes,  and  its  walls  grow  thicker,  the  intestinal  canal 
longer  and  more  capacious;  in  short,  all  the  digestive  organs  are 
more  adapted  to  an  animal  diet.  At  this  period  milk  alone  could  not 
satisfy  the  child.  It  may  be  dispensed  morning  and  evening,  but 
during  the  day  more  substantial  food  is  of  absolute  necessity " 
(Ammon). 

Should  illness  of  any  kind  occur  after  a  child  has  been  put  upon 
solid  diet,  it  should  at  once  be  given  only  fluid  food  again,  and  this 
does  not  mean  a  diet  of  tea  and  toast  water,  but  of  milk  or  meat 
broths. 


FOOD   FOR   YOUNG   CHILDREN. 


733 


Servants  are  often  very  careless  in  regard  to  the  food  which  they 
put  within  reach  of  young  children,  who  wish  to  eat  everything  they 
see,  and  ignorant  mothers  sometimes  give  children  at  the  breast  tea, 
coffee,,  or  beer,  and  their  older  children  are  allowed  to  eat  such  sub- 
stances as  the  skin  of  potatoes  and  fruits,  sausages,  or  canned  corn, 
with  the  result  of  causing  acute  gastritis  or  convulsions. 

On  the  other  hand,  children  should  not  be  allowed  to  grow  up 
with  too  little  variety  in  taste.  An  occasional  departure  from  strict 
rules  or  a  single  indulgence  in  some  ordinarily  prohibited  article 
.may  do  no  harm,  but  serve  to  gratify  and  educate  the  child. 

Young  children  of  four  or  five  years  of  age  or  more  commonly 
crave  sugar,  but  do  not  care  for  fatty  foods.  They  are  apt  also  to 
like  vegetable  acids,  and  are  therefore  fond  of  fruits.  These  acids 
are  wholesome,  and  the  fruit  is  laxative  and  healthful  when  ripe  and 
fresh. 

It  may  seem  superfluous  to  separately  name  the  chief  prohibited 
substances  which  must  be  kept  from  young  children,  but  experience 
proves  the  contrary,  and  when  common  sense  is  lacking  in  those 
who  are  entrusted  with  their  care,  a  written  list  of  these  foods  should 
be  given  them.  If  the  child's  food  is  too  coarse,  too  much  energy  is 
diverted  in  the  attempt  to  digest  it,  and  this  is  at  the  expense  of 
normal  growth  and  development.  Young  children  should  be  kept 
out  of  the  pantry  and  kitchen,  where  their  attention  is  attracted  by 
forms  of  food  which  they  cannot  have. 

It  is  estimated  by  Edward  Smith  that  in  proportion  to  its  weight, 
.  the  growing  child  requires  about  three  times  as  much  carbonaceous 
food  as  the  adult  and  six  times  as  much  animal  food. 

Foods  Forbidden  to  all  Young  Children. 

The  following  articles  are  particularly  indigestible  for  children, 
and  should  not  be  allowed  them  under  four  years  of  age,  and  most 
of  them  should  not  be  given  under  seven  or  eight  years  :  Fried  food 
of  all  kinds,  game,  salt  food,  the  flesh  of  swine  in  all  forms  (pickles, 
salads,  condiments,  except  salt),  "stews,"  the  "dressing"  of  fowl, 
sauces,  visceral  foods  (such  as  liver,  kidneys,  tripe,  etc.),  all  raw 
vegetables,  potatoes  (except  baked),  tomatoes  in  any  form;  the 
coarser  vegetables,  such  as  beets,  turnips,  cabbage,  etc. ;  fancy  bread, 
cake,  and  pastry  ;  griddle  cakes,  canned  food  of  all  kinds ;  fancy  con- 
fectionery, sweets,  and  preserves;  cheese,  rich  soups,  jellies,  dried  or 
unripe  and  overripe  fruits  (bananas,  so  often  given  to  young  children, 
are  very  bad  for  them),  nuts,  fruits  with  large  seeds,  such  as  grapes, 
the  skin  of  all  poultry,  fruits,  or  vegetables. 

All  food  should  be  plainly  and  thoroughly  cooked.  No  greasy 
or  highly  seasoned  dishes  are  permissible,  and  as  a  rule  twice-cooked 
meats  are  indigestible. 


734 


RATIONS,   DIETARIES. 


Tea,  coffee,  and  alcohol  in  every  form  must  be  withheld.  The 
two  former  beverages  interfere  with  digestion  and  make  the  child 
nervous,  and  the  latter  lays  the  foundation  for  a  permanent  alcohol 
habit.  Soda  water  with  sirups  should  not  be  given.  Too  much 
water  should  not  be  allowed  with  meals,  and  what  is  given  should 
not  be  ice  cold. 

Children,  as  they  grow  up,  should  continue  to  observe  regularity 
in  the  hours  for  taking  meals,  and  the  habit  of  perpetually  nibbling 
at  cake,  crackers,  and  confectionery  between  meals  should  not  be  tol- 
erated. It  is  best  for  young  children  not  to  be  put  to  sleep  immedi- 
ately after  their  most  substantial  meal  of  the  day.  As  they  require 
a  nap  in  the  early  afternoon,  many  advise  giving  this  meal  at  4  p.  m. 

The  following  is  a  useful  summary  (taken  in  part  from  Holt)  of 

General  Rules  for  Feeding  Young  Children. 

1.  Allow  time  for  meals. 

2.  See  that  the  food  is  thoroughly  masticated. 

3.  Do  not  allow  nibbling  between  meals. 

4.  Do  not  tempt  the  child  with  the  sight  of  rich  and  indigestible 
food. 

5.  Do  not  force  the  child  to  eat  against  its  will,  but  examine  the 
mouth,  which  may  be  sore  from  erupting  teeth ;  and  examine  the 
food,  which  may  not  be  properly  cooked  or  flavoured. 

If  good  food  is  refused  from  peevishness  merely,  remove  it  and 
do  not  offer  it  again  before  the  next  meal  time. 

6.  In  acute  illness  reduce  and  dilute  the  food  at  once. 

7.  In  very  hot  weather  give  about  one  fourth  or  one  third  less 
food,  and  offer  more  water. 

The  young  infant  depends  wholly  upon  animal  food,  and  derives 
the  necessary  carbon  largely  from  the  sugar  of  milk.  The  older 
child  lives  in  part  only  upon  animal  food,  and  begins  to  derive  addi- 
tional carbon  from  bread  and  other  cereal  foods. 

Quantity  of  Food  Required. — Experiments  have  been  made 
by  Ueffelmann,  Hasse,  and  others,  to  determine  the  necessary  per- 
centage of  albuminous  food  required  per  diem  per  kilogramme  of 
body  weight,  by  growing  children,  with  the  following  result : 

Average  weight  of  child. 


At  2  years 4      grammes.  12.5  kilogrammes. 

At  3  to  5  years :• 3.5         "  15 

At  8  to  II  years 2.5         "  24  " 

Thus  it  is  seen  the  percentage  of  albuminous  food  required  di- 
minishes as  the  child  gains  in  weight,  and  more  carbohydrate  food 
is  used  to  replace  it. 


FOOD   FOR   YOUNG   CHILDREN.  7,5. 

The  daily  average  quantity  of  food  required  by  each  child  in  an 
aggregate  of  twenty-eight  healthy  children  between  the  ages  of  two 
and  three  years  is  reported  by  Starr  to  be  as  follows :  Bread,  7.5 
ounces;  butter,  .98  ounce;  meat  (beef),  4.6  ounces;  potatoes,  3.9 
ounces;  milk,  32.6  fluid  ounces.  The  daily  average  for  each  child 
in  an  aggregate  of  twelve  children  between  the  ages  of  three  and 
six  years  was:  Milk,  48.6  fluid  ounces;  beef,  12.1  ounces;  rice,  13.0 
ounces;  bread,  10.3  ounces;  butter,  i.oS  ounce.  The  daily  average 
for  each  child  in  an  aggregate  of  twenty-four  children  between  the 
ages  of  four  and  ten  years  was:  Roast  beef,  12.46  ounces;  bread, 
10.23  ounces;  potatoes,  10.03  ounces;  butter,  .99  ounce;  milk, 
38.5  fluid  ounces. 

Dietaries  for  Young  Children. 
The  following  diets  are  recommended  by  Starr  as  types  for  use 
from  the  period  of  weaning  up  to  three  and  a  half  years  or  more: 

Diet  from  the  Twelfth  to  the  Eighteenth  Month  (Starr). 

7  A.  M.,  stale  bread  soaked  in  a  breakfast  cup  of  new  milk. 

10  A.  M.,  milk,  six  ounces,  and  soda  biscuit,  or  a  thin  slice  of  but- 
tered bread. 

2  p.  M.,  beef  tea,  six  ounces,  bread,  and  a  tablespoonful  of  rice 
and  milk  pudding. 

6  p.  M.,  same  as  first  meal. 

10  p.  M.,  a  tablespoonful  of  Mellin's  food  in  eight  ounces  of  milk. 
In  alternation  a  lightly  boiled  ^gg  with  bread  crumbs  and  six 

ounces  of  milk  may  be  given  at  7  a.  m.,  and  at  2  p.  m.  a  mashed 
baked  potato  moistened  with  four  tablespoonfuls  of  beef  tea,  two 
tablespoonfuls  of  junket. 

Diet  from  the  Eighteenth  to  the  Thirtieth  Month  (Starr). 

7  a.  m.,  new  milk,  eight  ounces ;  the  yolk  of  an  ^gg  lightly  boiled; 
two  thin  slices  of  bread  and  butter,  or  else  milk,  and  two  tablespoon- 
fuls of  well-cooked  oatmeal  or  wheaten  grits,  with  sugar  and  cream. 

11  A.M.,  milk,  six  ounces,  with  a  soda  biscuit  or  bread  and 
butter, 

2  p.  M.,  one  tablespoonful  of  rare  mutton  pounded  to  a  paste, 
bread  and  butter,  or  mashed  potatoes  moistened  with  good  dish 
gravy,  a  saucer  of  junket;  or  else  a  breakfastcupful  of  beef  tea  or 
mutton  or  chicken  broth,  a  thin  slice  of  stale  bread,  a  saucer  of  rice 
and  milk  pudding. 

6.30  p.  M.,  a  breakfastcupful  of  milk  with  bread  and  butter,  or 
soft  milk  toast. 


49 


736  RATIONS,   DIETARIES. 

Diet  from  Tiuo  and  a  Half  to  Three  and  a  Half  Years  of  Age  (/.  <f.,  for 
Children  who  have  cut  their  Milk  Teeth)  (Starr). 

-7  A.  M.,  one  or  two  tumblers  of  milk,  a  saucer  of  thoroughly 
cooked  oatmeal  or  wheaten  grits,  a  slice  of  bread  and  butter. 

II  A.  M.,  (if  hungry),  a  tumbler  of  milk  or  a  teacupful  of  beef  tea 
with  a  biscuit. 

2  p.  M.,  a  slice  of  underdone  roast  beef  or  mutton,  or  a  bit  of 
roast  chicken  or  turkey,  minced  as  fine  as  possible,  a  mashed  baked 
potato  moistened  with  dish  gravy,  a  slice  of  bread  and  butter,  a 
saucer  of  junket  or  rice  and  milk  pudding. 

7  p.  M.,  a  tumblerful  of  milk  and  a  slice  or  two  of  soft  milk  toast. 

Diet  from  Three  and  a  Half  Years  up  (Starr). 

Breakfast. — Every  day :  Milk,  porridge  and  cream,  bread  and 
butter. 

One  dish  only  each  day :  Fresh  fish,  eggs  lightly  boiled,  eggs 
poached,  eggs  scrambled,  eggs  (plain  omelet),  chicken  hash,  stewed 
kidney,  stewed  liver. 

Sound  fruits  may  be  allowed  before  and  after  the  meal,  according 
to  taste,  as  oranges  without  pulp,  grapes  (seeds  not  to  be  swal- 
lowed), peaches,  thoroughly  ripe  pears,  and  cantaloupes. 

Dinner. — Every  day :  Clear  soup,  meat  roasted  or  broiled  and 
cut  into  small  pieces,  bread  and  butter. 

Two  dishes  each  day :  Potatoes  baked,  potatoes  mashed,  spinach, 
stewed  celery,  cauliflower,  hominy,  macaroni  (plain),  peas,  string 
beans  (young),  green  corn  (grated). 

Junket,  rice-and-milk  or  other  light  pudding,  and  occasionally 
ice  cream,  may  be  allowed  for  dessert. 

Supper. — Every  day  :  Milk,  milk  toast  or  bread  and  butter,  stewed 
fruit. 

From  the  third  to  the  fifth  year  the  child  has  twenty  teeth,  and 
often  three  meals  a  day  suffice,  although  from  the  third  to  the  fourth 
year  four  may  be  given.  After  three  years  of  age  it  is  not  possible  to 
lay  down  definite  rules  for  the  quantity  of  food  allowed.  In  health, 
the  appetite  may  be  taken  as  a  fair  guide,  and  the  child  will  not  eat 
too  much  if  taught  to  eat  very  slowly  and  thoroughly  chew  each  . 
mouthful. 

When  the  second  set  of  teeth  begin  to  replace  the  deciduous 
or  milk  teeth,  which  gradually  decay,  digestion  is  sometimes  inter- 
fered with  temporarily  from  lack  of  ability  to  masticate  thoroughly, 
and  the  food  should  be  thoroughly  subdivided  before  it  is  offered  to 
the  child. 

The  following  is  the  sample  diet  given  by  Holt  for  a  child  eight- 
een months  old : 


FOOD  FOR  YOUNG  CHILDREN.  jyj 

First  Meal. — A  tablespoonful  of  some  cereal  with  salt  and  one 
tablespoonful  of  cream,  one  half  pint  of  milk. 

Second  Meal. — One  half  pint  of  milk. 

Third  Meal. — One  tablespoonful  of  scraped  meat,  two  small 
pieces  of  dried  bread,  half  a  pint  of  milk. 

Fourth  Meal. — Milk. 

Fifth  Meal. — Milk  with  farina  or  arrowroot. 

Instead  of  scraped  meat  (page  97),  beef  juice  (page  100)  or  a  soft 
cooked  t%%  may  be  substituted  occasionally.  Of  the  beef  juice  from 
one  to  three  tablespoonfuls  may  be  given  at  a  time. 

*'  The  quantity  of  milk  allowed  at  a  .single  feeding  for  a  child 
during  the  second  year  should  be  from  eight  to  ten  ounces  during 
the  first  half  and  from  ten  to  twelve  ounces  during  the  latter  half  of 
the  year"  (Holt). 

The  following  rules  for  meats  and  vegetables  for  young  children 
are  given  by  Holt : 

"  Meats. — After  eighteen  months,  if  most  of  the  teeth  are  pres- 
ent, once  daily,  finely  bruised  or  scraped  rare  roast  beef,  roast  lamb, 
broiled  mutton  chop  or  beefsteak,  white  meat  of  chicken  or  turkey, 
fresh  fish  boiled  or  broiled — bones  the  only  objection. 

"  Vegetables. — Potatoes  (not  till  after  second  year)  roasted, 
peas,  asparagus  tops,  spinach,  string  beans,  boiled  onions,  stewed 
celery ;  all  should  be  very  well  cooked,  in  season,  and  fresh." 

Fruits  are  very  wholesome  food  for  young  children  from  three  or 
four  years  onward,  provided  they  are  properly  selected  and  not 
allowed  in  excess,  which  is  almost  the  only  source  of  trouble  from 
them.  They  serve  to  keep  the  blood  in  good  condition,  favor  diges- 
tion, and  prevent  constipation.  After  the  fifteenth  month  two  to 
six  teaspoonsfuls  of  orange  juice  may  be  given,  and  a  little  later  the 
soft  pulp  of  two  or  three  stewed  prunes,  or  a  half-baked  or  stewed 
apple. 

A  child  three  or  four  years  of  age  may  have  a  piece  of  ripe  pear, 
peach,  or  plum,  or  strawberries  in  season.  Cherries  and  bananas 
should  be  forbidden.  Grape  juice  is  allowed  without  the  skin  or 
seeds.  During  very  hot  weather  great  caution  should  be  observed 
in  giving  fruit  of  any  kind  to  infants. 

Bread,  rice,  oatmeal,  and  other  cereal  foods  should  always  enter 
largely  into  the  dietary  of  healthy  children  after  they  are  able  to 
digest  them.  Their  fats  should  be  derived  chiefly  from  butter  and 
cream.  The  best  fruits  for  them  are  oranges,  cooked  apples,  and 
stewed  prunes. 

Children  between  three  and  four  years  of  age  should  be  fed 
when  in  health  four  times  a  day — at  7  a.  m.,  10.30  a.  m.,  1.30  p.  m., 
and  6  p.  m.     The  following  is 


7^g  RATIONS,   DIETARIES. 

Holfs  ^^  Sample  Diet  for  a  Child  Four   Years  Old."' 

First  Meal. — Half  an  orange,  one  and  a  half  tablespoonfuls  of 
oatmeal  or  hominy,  well  salted,  with  two  tablespoonfuls  of  cream, 
but  no  sugar,  and  one  glass  of  milk. 

Second  Meal. — A  glass  of  milk  or  cup  of  broth  and  one  slice  of 
stale  bread. 

Third  Meal. — Meat — either  steak,  chop,  or  chicken — one  green 
vegetable  (e.  g.,  spinach),  one  starchy  vegetable  (e.  g.,  potato),  water 
to  drink,  stewed  prunes  fftr  dessert. 

Fourth  Meal. — Bread  and  milk  or  milk  toast. 

Desserts  for  Children. 

"After  two  and  a  half  years — plain  custard,  ice  cream  (not 
oftener  than  once  a  week),  rice  pudding  (no  raisins),  baked  apple, 
stewed  prunes  "  (Holt). 

The  following  rules  for  feeding  young  children  are  given  by 
Adams  : 

When  the  child  has  its  first  sixteen  teeth  it  is  to  be  given  more 
varied  food  than  before,  such  as  stale  bread  and  butter,  crackers, 
mashed  potato  and  gravy,  scraped  beef  sandwiches  with  salt  or 
sugar,  a  piece  of  rare  beef,  or  a  chicken  bone  to  suck.  He  gives 
during  the  period  of  sixteen  teeth  : 

6  A.  M.,  a  cup  of  milk,  cream  biscuit,  or  slice  of  buttered  bread ; 
8  A.  M.,  stale  bread  broken  and  soaked  in  a  tumblerful  of  rich  milk ; 
12  M.,  slice  of  buttered  bread,  half  a  pint  of  weak  beef  tea,  or  mutton 
or  chicken  broth ;  4  p.  m.,  tumblerful  of  milk  with  cracker  or  a  slice 
of  buttered  bread ;  8  p.  m.,  a  tumblerful  of  milk  with  bread  or 
crackers. 

At  the  end  of  the  period  of  sixteen  teeth : 

6  A.  M.,  bread  or  crackers  with  half  a  pint  of  milk  ;  8  a.  m.,  a 
tablespoonful  of  oatmeal,  cracked  wheat,  or  corn-meal  mush  with 
milk  and  a  couple  of  slices  of  buttered  bread;  12  m.,  bread  and 
butter,  milk,  and  a  soft-boiled  ^%g ;  4  p.  m.,  a  piece  of  rare  roast 
beef  to  suck,  mashed  boiled  potatoes,  moistened  with  dish  gravy, 
bread  and  milk,  and  a  small  portion  of  rice,  bread  jelly,  or  farina ; 
8  p.  M.,  milk  and  bread  or  crackers. 

Adams  usually  prefers,  however,  to  give  milk  and  oatmeal  water 
or  barley  water  through  the  second  summer. 

If  the  child  vomits  sour  food,  a  little  alkali  should  be  added  to 
the  food  (sodium  bicarbonate,  etc.).  Diarrhoea  may  be  excited  by  a 
too  solid  diet. 

He  prescribes  for  a  child  with  all  the  milk  teeth,  and  able  to 
walk,  up  to  the  third  year  : 

8  A.  M.,  well-cooked  oatmeal,  wheaten  grits,  or  corn-meal  mush, 


FOOD   FOR  YOUNG  CHILDREN. 


739 


with  a  liberal  supply  of  milk,  cold  bread,  and  butter,  a  piece  of  finely 
cut,  tender  beefsteak  or  a  soft-boiled  egg;  12  m.,  bowl  of  chicken  or 
oyster  soup,  or  weak  beef  tea,  milk  with  bread  or  crackers,  and 
butter;  4  p.  m.,  roast  beef,  mutton,  chicken,  or  turkey,  fresh  white 
fish,  mashed  white  potato  moistened  with  gravy,  bread  and  butter, 
and  rice  and  milk ;  8  p.  m.,  milk  with  bread  or  crackers. 

Bread  and  milk  or  butter  may  be  given  between  the  first  and  sec- 
ond meal  or  before  the  first,  also  ripe  fruit  later. 

For  a  child  from  the  third  to  the  fifth  year  Adams  gives: 

Breakfast. — Corn-meal  mush,  oatmeal,  wheaten  grits,  hominy, 
plenty  of  cream ;  potatoes,  baked  or  stewed ;  eggs,  poached,  soft- 
boiled,  omelet;  fish,  fresh  broiled;  meats:  beef  hash,  broiled  steak, 
stewed  liver  and  kidneys,  lamb  chops,  chicken  fricassee ;  tomatoes, 
sliced ;  bread  (cold) ;  light  Graham,  entire  wheat,  corn  muffins 
(plain),  and  occasionally  Graham,  corn,  and  rice  cakes ;  fresh,  ripe 
Iruit. 

Luncheon. — Soups:  oyster,  clam,  bean,  chicken,  consomm/ ;  vege- 
tables :  potatoes,  baked  or  stewed,  sliced  tomatoes ;  beefsteak,  lamb 
chop,  cold  roast  lamb;  cold  rolls,  soda  crackers;  fruits  in  season; 
rice  and  milk. 

Dinner. — Soups  :  consomm^,  oyster,  cream  of  barley,  potato, 
chicken ;  chicken,  stewed ;  fish,  baked,  broiled,  or  boiled ;  roast 
beef,  chicken,  lamb  ;  potatoes,  rice,  cauliflower,  macaroni,  peas, 
tomatoes,  beans ;  bread,  well-cooked  wheat.  Dessert :  rice  and 
milk,  light  pudding,  ice  cream,  fruits,  and  berries. 

Teething  and  Food. 

Much  illness  and  digestive  disturbance  in  infancy  and  early  child- 
hood is  popularly  ascribed  to  "teething,"  and  the  gums  do  occasion- 
ally become  swollen  and  inflamed  during  dentition,  but  the  evils  of 
this  process  are  exaggerated  in  the  lay  mind  and  wrong  feeding  is 
much  more  often  accountable  for  the  disturbance.  In  regard  to 
this  matter  Adams  says,  "  My  experience  has  taught  me  that  when- 
ever the  child  has  become  ill  during  this  physiological  process,  some 
other  cause  than  the  mere  cutting  of  the  teeth  can  be  found  to 
account  for  the  illness." 

Sleep  and  Feeding. 
The  relation  of  sleep  to  infant  feeding  is  very  well  summarised 
by  Adams  as  follows :  "  A  young  infant  has  nothing  to  do  but  eat 
and  sleep.  As  soon  as  he  is  fed  he  will  take  a  nap  and  will  prob- 
ably sleep  for  an  hour  and  a  half.  After  the  first  year  the  naps  be- 
come shorter  and  less  frequent.  During  the  second  year  a  nap  in 
the  morning  after  breakfast,  one  in  the  afternoon  about  one  or  two 


740 


RATIONS,   DIETARIES. 


o'clock  for  an  hour  or  an  hour  and  a  half  are  usually  sufficient,  and 
these  naps  should  be  insisted  upon  for  the  rest  of  his  mind  and  body, 
and  to  enhance  his  growth  and  health.  As  the  child  attains  the 
third  year,  he  can  usually  drop  the  morning  nap.  The  afternoon 
one  should  be  insisted  upon  very  soon  after  the  child  has  its  noon- 
day meal,  in  winter  as  well  as  in  summer." 

DIET    FOR    SCHOOL    CHILDREN. 

Too  much  attention  cannot  be  given  by  teachers  to  the  diet  of 
the  pupils  under  their  care  in  boarding  schools,  and  they  should 
exercise  some  supervision  in  regard  to  the  matter  in  day  schools 
as  well,  for  the  subject  is  often  ill  understood  by  parents. 

The  age  for  training  most  school  children  is  from  the  tenth  to 
the  seventeenth  or  eighteenth  year.  During  the  entire  time  both 
mind  and  body  are  undergoing  development,  which  in  many  in- 
stances is  exceedingly  rapid,  and  in  the  midst  of  this  period  the 
condition  of  puberty  is  attained,  which  in  itself  requires  additional 
care  and  watchfulness,  especially  in  girls. 

With  the  present  system  of  kindergarten  training  the  attendance 
at  school  of  most  children  begins  much  younger  than  the  age  men- 
tioned. Throughout  the  whole  school  period  the  growth  of  the 
body  is  continued  until  almost  completed.  The  individual  organs 
and  structures  incr.ease  in  actual  size,  and  there  are  unusual  de- 
mands, therefore,  upon  the  functions  of  absorption  and  assimilation. 
The  food  must  be  abundant  and  of  the  proper  character  to  furnish 
new  tissue  and  to  yield  energy  in  the  form  of  heat  and  muscular 
activity.  The  former  condition  is  met  by  a  proper  allowance  of 
animal  food  in  the  diet,  and  the  latter  by  sufficient  hydrocarbona- 
ceous  material.  The  food  should  also  contain  salts  of  lime,  to  meet 
the  requirements  of  formation  of  the  bones  and  teeth.  While  the 
material  or  structural  development  of  the  body  progresses,  there  is 
also  a  marked  development  in  the  functions  of  the  various  organs ; 
the  muscles  are  trained  to  act  with  vigor  and  with  proper  co-or- 
dination, and  the  nervous  system  is  constantly  receiving  and  storing 
new  impressions  and  regulating  their  transmission  and  the  proper 
relations  of  inhibitory  and  reflex  actions.  The  metabolic  processes 
of  the  body  are  extremely  active  and  the  digestive  secretions  are 
vigorous.  To  maintain  the  proper  standard,  therefore,  of  growth 
and  development  requires  care  in  the  selection  of  the  right  quantity 
and  quality  of  "  fuel  "  or  food  for  the  body,  and  the  lack  of  such 
care  too  often  lays  the  foundation  for  future  disease,  or  results  in 
an  enfeebled  constitution  with  greatly  diminished  resisting  power  of 
coping  with  emergencies  which  may  arise. 

Many  children  inherit  feeble  constitutions  or  diatheses,  such  as 


DIET   FOR   SCHOOL  CHILDREN. 


741 


the  scrofulous,  rachitic,  and  gouty,  which  must  be  combated 
throughout  the  whole  period  of  childhood.  Such  children  are  better 
kept  at  home,  where  they  can  be  under  constant  observation  and 
proper  dietetic  treatment,  or  country  schools  can  be  found  for  them 
where  such  matters  are  made  the  subject  of  special  consideration. 

Many  cases  of  anaemia  and  chlorosis,  which  are  so  commonly 
seen  in  young  girls  during  or  shortly  after  the  attainment  of  the 
condition  of  puberty,  are  directly  traceable  to  malnutrition  from 
faulty  diet.  Girls  take  much  less  exercise  than  boys  as  a  rule,  and 
are  more  apt  to  become  constipated.  This  difficulty  may  be  en- 
hanced by  a  lack  of  sufficient  fresh  vegetables  or  fruit  in  their  diet, 
and  if  prolonged  it  is  enough  in  itself  to  cause  anaemia.  The  latter 
may  also  be  brought  about  by  insufficient  good  animal  food.  It 
should  be  the  imperative  duty  of  every  head  master  of  a  school  for 
children  to  realise  the  responsibilities  of  rightly  developing  the 
physical  constitutions  of  those  entrusted  to  his  care,  and  to  make  a 
thorough  study  of  the  questions  of  dietetics  involved.  He  should 
remember  that  the  mind  keeps  on  developing  long  after  the  body, 
and  that  the  period  under  discussion  is  one  in  which  the  constitution 
of  the  individual  is  established  for  the  remainder  of  life,  and  success 
in  digestion  and  assimilation  is  of  greater  importance  than  success 
in  mental  attainments. 

Variety. — An  important  consideration  in  school  diet  is  to  pre- 
vent monotony,  which  becomes  so  common  from  economic  reasons, 
or  more  often  from  carelessness.  It  is  much  easier  to  yield  to 
routine  and  force  of  habit  or  to  leave  the  matter  to  the  indiscretions 
of  an  unintelligent  cook.  But  a  little  study  and  thought  expended 
upon  this  subject  can  always  result  in  furnishing  variety  in  a  whole- 
some diet  without  material  increase  of  expense. 

Hours  for  Mea^Is. 
The  hours  for  study  and  for  meals  should  be  so  regulated  that 
sufficient  time  should  be  allowed  before  each  meal  for  children  to 
wash  and  prepare  themselves  comfortably  without  going  to  the 
table  excited  by  hurry,  and  they  should  be  required  to  remain  at  the 
table  throughout  a  fixed  time,  never  being  allowed  to  hastily  swal- 
low their  food  in  order  to  complete  an  unfinished  task  or  game.  An 
interval  of  half  an  hour  or  more  should  intervene  for  recreation 
after  meals,  in  order  that  digestion  may  be  well  under  way  before 
any  mental  exertion  is  required.  Constant  nibbling  at  food  between 
meals  should  be  forbidden  ;  it  destroys  the  appetite,  increases  the 
saliva,  and  interferes  with  gastric  digestion.  The  number  of  meals 
for  children  should  be  adapted  to  the  age  of  the  pupils.  For 
young  children  from  ten  to  twelve  or  thirteen  years  of  age  it  may 
be  necessary  to  furnish  food  somewhat  oftener  than  for  older  ones. 


7At 


RATIONS,   DIETARIES. 


If  children  live  at  a  distance  from  their  school,  or  if  they  are 
weak  and  easily  fatigued  and  inclined  to  sleep  over  in  the  morning, 
their  hours  for  study  should  be  so  adjusted  that  they  are  never 
obliged  to  hurry  their  eating  in  order  to  be  on  time  for  school  work.  _ 
The  teachers  should  consider  themselves  quite  as  responsible  for 
regulating  this  matter  as  are  the  parents. 

Children  should  never  be  hurried  off  to  school  in  the  morning 
with  an  insufficient  and  rapidly  eaten  breakfast.  Their  appetites 
are  often  poor  at  this  hour  from  the  effects  of  an  ill-ventilated 
sleeping  apartment,  and  if  they  are  subsequently  kept  at  school  for 
five  hours  without  luncheon  they  are  very  ill  prepared  for  mental 
work.  Or  they  ride  to  school  without  exercise  after  a  hasty  break- 
fast, take  a  hurried  cold  lunch  at  noon,  and  perhaps  a  warmed-over 
late  dinner,  and  at  six  or  seven  o'clock  a  fourth  meal,  after  which 
they  are  expected  to  study  and  go  to  bed. 

It  is  being  more  and  more  realised  by  teachers  and  the  public  in 
general  that  the  breaking  down  of  health  at  school  is  quite  as  often, 
if  not  oftener,  due  to  impoverished  nutrition  than  to  overwork. 

A  fact  which  is  often  overlooked  in  the  dietetic  treatment  of 
growing  children  is  that  their  digestive  processes  are  so  active  that 
the  stomach  is  emptied  somewhat  sooner  than  in  the  case  of  adults, 
and  their  meals  being  promptly  absorbed,  it  is  natural  for  them  to 
■become  hungry  if  the  intervals  between  the  hours  of  eating  are  pro- 
longed. In  some  schools,  children  are  given  their  last  meal  of  the 
day  at  six  o'clock  in  the  evening,  and  they  may  not  breakfast  until 
seven  or  half  past  seven  or  even  later,  leaving  an  interval  of  over 
thirteen  hours  during  which  they  have  no  food  at  all.  The  even- 
ing meal  is  usually  made  light,  on  the  ground  that  they  can  sleep 
better,  and  it  is,  therefore,  sooner  digested.  Robust  children  can 
perhaps  thrive  on  this-  treatment,  but  those  less  strong  are  injured 
by  it.  For  some  school  children  of  from  ten  to  fourteen  years  of 
age  it  will  be  much  better  to  give  the  evening  meal  later,  at,  say, 
half  past  seven  o'clock,  and  the  breakfast  at  half  past  six  or  seven, 
and  if  they  awaken  hungry  during  the  night  there  is  no  harm  in 
their  having  a  glass  of  milk  and  a  cracker. 

Very  delicate  children  whose  appetites  are  poor  and  who  do  not 
do  proper  justice  to  their  regular  meals  should  be  given  an  extra 
allowance  of  hot  broth  or  hot  milk  or  an  occasional  cup  of  chocolate 
with  bread  and  butter  and  rusk  between  meals. 

These  general  rules  are  applicable  in  cases  of  children  who, 
during  one  or  two  years,  seem  to  develop  with  extraordinary  sud- 
denness and  rapidity,  growing  sometimes  two  inches  or  more  in  six 
months  and  attaining  a  height  quite  disproportionate  to  their  frames. 
The  demands  of  this  rapid  growth  must  be  met  by  proper  nutrition 
or   serious  subsequent   impairment   of  vitality   may  result.      Such 


DIET  FOR  SCHOOL  CHILDREN. 


743 


children  should  have  their  meals  made  tempting  by  good  cooking 
and  pleasant  variety  as  well  as  an  agreeable  appearance  of  the 
food. 

Meat  which  is  carved  in  unsightly  masses  and  vegetables  which 
are  sodden  and  tasteless  will  be  refused,  and  an  ill  attempt  is  made 
to  supply  the  deficiency  in  proper  food  by  eating  indigestible  candy, 
nuts,  etc.  Children  often  have  no  natural  liking  for  meat,  and  pre- 
fer puddings,  pastry,  or  sweets  when  they  can  obtain  them,  and  it  is 
the  more  important  that  meat  should  be  made  attractive  to  them  at 
the  age  when  they  need  it. 

It  is  unnecessary  to  discuss  further  questions  which  after  all 
must  be  controlled  by  tact  and  circumstances  of  individual  cases, 
and  the  line  must  be  drawn  with  care  between  making  a  child  too 
fastidious  on  the  one  hand  in  regard  to  the  nature  of  its  food,  and 
on  the  other  impairing  its  constitution  by  monotony  of  diet  and 
ill-cooked  viands.  Children  at  school  should  be  especially  required 
to  eat  slowly,  for  the  habit  of  fast  eating  is  almost  contagious,  and 
as  it  is  much  easier  to  acquire  than  to  overcome,  the  foundation  of 
dyspepsia  and  lifelong  discomfort  may  be  laid  in  this  way  in  child- 
hood. 

A  Sample  Diet. 

If  early  rising  is  insisted  upon,  a  child  should  never  be  set  at  any 
task  before  breakfast,  especially  in  winter,  and  if  it  is  not  expedient 
to  serve  a  full  breakfast  at  half  past  six  or  seven  the  child  should  be 
given  a  bowl  of  hot  milk  and  bread,  or  a  cup  of  cocoa  with  a  roll,  or 
other  light  food:  breakfast  may  be  served  later  after  the  first  exer- 
cises of  the  morning,  and  should  be  a  substantial  meal  with  animal 
food  in  the  form  of  either  fish,  or  eggs,  or  cold  meat  of  some  sort, 
with  porridge  of  wheaten  grits,  or  hominy  with  milk  or  cream  and 
abundant  sugar,  also  bread  and  butter,  with  some  sweets  in  the  form 
of  jam,  or  marmalade,  or  stewed  fruit.  Dinner,  which  should  always 
be  served  near  the  middle  of  the  day,  should  comprise  meat,  pota- 
toes, with  one  or  two  green  vegetables,  and  some  form  of  sweet  pud- 
ding. The  supper  it  is  generally  admitted  should  comprise  only 
easily  digestible  articles  of  food,  and  such  substances  as  pastry, 
cheese,  and  meats  are  better  omitted.  It  should  consist  of  either  a 
porridge  with  milk  or  cream,  or  a  light  farinaceous  pudding  of  rice, 
tapioca,  sago,  and  the  like,  with  bread  and  butter,  and  some  simple 
form  of  preserve,  or  stewed  apples  or  prunes,  or  very  light  plain 
cake,  or  a  good  bowl  of  nutritious  broth  with  bread  or  crackers 
may  be  substituted  for  the  porridge  or  pudding.  It  will  sometimes 
be  found  best  to  serve  this  meal  at  seven  o'clock  or  half  past  seven, 
and  if  hungry  the  child  may  be  given  a  slice  of  bread  and  butter 
and  a  cup  of  weak  tea  or  coffee,  mostly  hot  milk,  at  half  past  five  or 
six  o'clock. 


744 


RATIONS,  DIETARIES. 


Sample  Diet  from  a  Well-knmvn  Boys'  School  in  New  England. 

Breakfast,  7.30  A.  M. — Oatmeal.  Bread  and  butter.  Stew  or  hashed 
meat,  or  beefsteak  or  chops.     Twice  a  week,  griddle  cakes  with  sirup.. 

Dinner,  i  p.  m. — Soup.  Fish  once  or  twice  a  week.  Meat,  either 
roast  beef,  beefsteak,  mutton,  or  chicken.  Potatoes  and  green  vege- 
tables in  season.    Pudding,  or  pie,  or  plain  cake,  and  lemonade.    Fruit. 

Supper,  7  p.  M. — Cold  meat,  or  hashed  meat,  or  fish  balls.  Pota- 
toes.    Bread  and  butter.     Cake.     Preserved  fruits. 

Time  allorued for  Meals. — Breakfast  and  supper,  each  half  an  hour ; 
dinner,  three  quarters  of  an  hour.  Intervals  of  rest  or  recreation 
for  the  younger  boys  (thirteen  to  fourteen  years),  after  breakfast, 
half  an  hour;  before  dinner,  three  quarters  of  an  hour;  after  dinner, 
two  hours  and  a  half;  before  and  after  supper,  fifteen  minutes. 

On  Sundays,  breakfast  an  hour  and  dinner  half  an  hour  later  than 
on  week-days,  and  supper  five  hours  after  dinner. 

Some  of  the  more  important  articles  of  school  diet  require  special 
mention. 

Bread,  as  a  rule,  should  be  made  of  whole  meal,  but  must  not 
be  too  coarse.  The  advantage  of  this  bread  for  children  consists  in 
its  containing  a  larger  proportion  of  salts,  which  they  need,  than  is 
found  in  refined  white  flour,  and  butter  should  be  freely  served  with 
it,  to  supply  the  deficiency  of  fats  which  exist  in  wheat.  Children 
need  fat,  but  they  do  not  digest  meat  fat  well  as  a  rule,  and  are  very 
apt  to  dislike  it.  They  will  often  take  suet  pudding,  however,  when 
hot  mutton  fat  wholly  disagrees  with  them. 

Milk  should  be  freely  supplied  not  only  in  the  form  of  puddings 
and  porridges,  but  as  an  occasional  beverage,  and  children  should  be 
made  to  understand  that  when  hungry  they  can  obtain  a  glass  of 
milk,  or  a  bowl  of  crackers  or  bread  and  milk,  for  the  asking. 

Chambers  says,  "The  best  luncheon  that  a  growing  young  man 
can  have  is  a  dish  of  roast  potatoes  well  buttered  and  peppered  and 
a  draught  of  milk." 

Fresh  Fish,  eggs,  and  bacon  are  all  wholesome  and  serviceable 
foods  for  children,  and 

Meat,  as  a  rule,  may  be  given  twice  a  day,  but  not  oftener.  It 
may  sometimes  be  advisable  to  give  it  but  once  a  day  when  fish  or 
eggs  are  supplied ;  it  should,  however,  always  be  given  at  least  once 
daily,  and  better  twice  to  rapidly  growing  children.  Large,  strong 
boys  require  a  great  deal  of  meat,  and  its  use  should  not  be  stinted. 
The  larger  boys  may  eat  from  seven  to  nine  or  even  twelve  ounces 
of  cooked  meat  as  a  ration,  although  many  children  may  not  require 
so  much,  the  smaller  boys  doing  well  with  from  five  to  six  ounces 
and  the  older  boys  with  from  seven  to  eight  ounces  daily. 

During  midwinter,  when  fresh  vegetables  are  almost  unobtain- 


DIET  FOR   SCHOOL  CHILDREN.  7^5 

able  in  severe  climates,  vigorous  boys  are  apt  to  have  too  much  meat 
given  them,  and  Yeo  calls  attention  to  the  fact  that  eczema  may  be 
produced  in  them  by  a  too  exclusive  animal  diet. 

Sweets.— The  greater  number  of  children  have  a  natural  craving 
for  sweets.  The  important  role  of  sugars  in  furnishing  energy  for 
the  body  has  been  discussed  (page  7),  and  the  energy  developed  in 
active  childhood  necessitates  the  consumption  of  a  larger  proportion 
of  sugar  than  is  required  by  adults.  The  craving  of  children  for 
confections,  candy,  etc.,  furnishes  a  true  indication  of  the  actual 
requirements  of  Nature,  and  it  must  be  admitted  that  a  certain 
amount  of  wholesome  candy,  like  plain  molasses  candy,  not  only 
does  most  children  no  harm,  but  may  serve  them  as  an  excellent  food. 
The  main  difficulty  with  such  forms  of  sugar,  however,  is  that  chil- 
dren are  not  furnished  with  a  proper  proportion  of  sugar  with  their 
meals,  and  the  meals  themselves  are  not  so  regulated  as  to  prevent 
their  becoming  very  hungry  between  times;  consequently,  if  they  can 
obtain  candy,  which  satisfies  them  for  the  time,  they  are  very  apt  to 
eat  too  much,  with  the  result  of  producing  more  or  less  dyspepsia 
and  diminishing  the  normal  appetite.  If  a  little  pains  be  taken  to 
give  such  children  a  slice  of  bread  and  butter  with  a  little  honey  or 
jam  between  meals  and  a  proper  proportion  of  saccharine  food 
with  their  meals,  they  are  much  less  likely  to  obtain  candy  surrep- 
titiously and  gorge  themselves  with  it.  Simple  forms  of  well-cooked 
pastry  and  of  cakes  with  stoned  raisins  should  be  furnished  as  des- 
sert occasionally.  It  is  better  to  give  such  food  from  time  to  time 
with  the  meals  under  proper  supervision  than  to  have  children  in- 
dulge themselves  in  it  surreptitiously. 

Alcohol  in  every  form  should  be  absolutely  excluded.  If  given 
during  early  youth  it  is  particularly  prone  to  develop  a  taste  which 
may  become  uncontrollable  in  later  years.  The  only  exceptions  10 
this  rule  are  some  sickly  and  anaemic  children  who  are  especially 
under  the  physician's  care. 

Habit. — Many  children  acquire  habits  of  dislike  or  even  disgust 
for  certain  articles  of  food,  which  become  so  fixed  in  later  life  that 
they  find  it  very  inconvenient,  especially  when  placed  in  circum- 
stances, as  in  travelling,  where  one  cannot  always  obtain  the  accus- 
tomed diet,  and  giving  in  to  such  habits  is  often  a  serious  obstacle 
to  normal  development.  There  are  children  who  acquire  a  dislike 
for  meat  and  who  persistently  refuse  to  take  it,  until  they  become 
anaemic  and  feeble,  and  there  are  others  who  refuse  fresh  vegetables, 
which  they  need.  It  is  a  great  misfortune  for  a  child  to  be  indulged 
in  such  likes  or  dislikes.  With  a  little  tact  and  persuasion  the  repug- 
nance can  usually  be  overcome  before  the  habit  becomes  rooted, 
and  these  questions  are  very  largely  a  matter  of  proper  education. 
How  often  is  the  physician   baffled   in  the  treatment  of  a  severe 


746 


RATIONS,   DIETARIES. 


disease  like  typhoid  fever,  which  requires  the  use  of  a  milk  diet,  by 
the  patient's  insisting  that  he  has  never  been  able  to  drink  milk  since 
childhood!  If  there  be  any  taste  which  is  natural  to  all  men  it  is 
that  for  milk,  upon  which  all  must  live  during  early  infancy ;  and 
while  it  is  better  after  a  certain  period  of  growth  to  restrict  the 
quantity  of  milk  in  the  diet,  there  is  no  reason  at  all  why  children 
should  not  retain  a  normal  fondness  for  it.  There  are,  no  doubt, 
cases  in  which  it  seriously  disagrees  (see  page  6i),  but  they  are  ex- 
ceptional as  compared  with  the  number  of  persons  who  can  digest 
milk,  when  properly  prepared,  with  perfect  ease,  but  whose  antipathy 
for  it  prevents  them  from  taking  it  in  the  emergencies  which  may 
befall  them  in  acute  disease. 

Children  who  object  to  vegetables  can  sometimes  learn  to  eat  them 
when  cooked  in  an  unusually  attractive  manner  or  served  in  soup. 

Overeating  should  be  guarded  against,  for  habits  of  gluttony 
may  be  acquired  in  youth,  especially  between  puberty  and  full  de- 
velopment, which  are  never  overcome,  and  which  may  lead  to  vis- 
ceral distention  and  hypertrophy,  obesity  and  other  troubles,  which 
develop  in  adult  life.    The  habit  of  slow  eating  should  be  insisted  upon. 

Hxercise. — As  a  general  rule,  active  muscular  exercise  in  chil- 
dren disturbs  their  digestive  processes  far  less  than  mental  effort 
when  taken  immediately  after  meals,  and  every  adult  is  familiar 
with  the  romping  which  children  can  undertake  straightway  after 
dinner,  often,  though  not  always,  with  impunity,  whereas  a  pro- 
portionate amount  of  exercise  on  the  part  of  an  adult  might  pro- 
duce a  severe  dyspeptic  attack.  It  is  well  to  allow  children  to  play 
but  moderately  immediately  after  eating,  and  to  require  no  mental 
work  of  them  at  such  times. 

For  some  reason  the  diet  in  girls'  schools  is  apt  to  be  much  less 
carefully  regulated  than  in  corresponding  schools  for  boys.  This 
applies  not  only  in  the  United  States,  but  it  has  been  found  the  com- 
mon experience  in  England  and  France;  it  is  the  more  unfortunate, 
since  girls  from  their  greater  delicacy  of  constitution,  especially  at  the 
period  of  puberty,  require  more  careful  nurture.  Differences  in  habits 
and  exercise  and  outdoor  recreation,  no  doubt  in  part,  are  respon- 
sible for  the  comparative  lack  of  proper  development  in  some  girls' 
schools  as  compared  with  boys',  but  this  should  be  recognised  and 
regulated  with  as  much  care  as  the  diet. 

During  the  establishment  of  puberty  it  is  best  for  children  to 
avoid  stimulating  and  highly  seasoned  food,  and  eating  late  at  night, 
which  is  apt  to  excite  the  sexual  organs  reflexly  and  cause  lascivi- 
ous dreams.  Alcohol  should  be  wholly  forbidden.  Its  use  by  young 
girls  is  said  to  bring  menstruation  earlier.  Some  articles  of  diet 
have  a  reputed  aphrodisiac  effect,  but  this  is  very  slight ;  such  are 
oysters,  eggs,  peppers,  and  champagne. 


HOSPITAL  DIETARIES. 


HOSPITAL   DIETARIES. 


H7 


Statistics  of  the  most  economical  quantity  and  quality  of  food 
for  men  in  health,  and  under  different  conditions  of  activity,  have 
been  very  accurately  and  practically  determined,  but  such  data  for 
invalids  are  in  most  cases  unobtainable,  and  obviously  so,  for  the 
condition  of  individual  cases  and  the  severity  of  diseases  are  con- 
stantly varying,  and  no  definite  rules  for  the  exact  quantity  of  food 
needed  could  be  formulated  which  would  be  of  general  application, 
for  this  reason  in  many  hospitals  no  attempt  is  made  to  classify  the 
diet  beyond  the  very -elementary  subdivisions,  consisting,  first,  of 
milk  diet — i.  e.,  milk  alone,  or  of  milk  with  a  little  bread,  and  light 
farinaceous  food  ;  secondly,  the  "  full  diet,  "  which  is  commonly 
known  either  by  that  name  or  as  "house  diet  "  or  "ordinary  diet." 
Where  no  further  general  classification  of  the  diet  is  attempted,  it  is 
customary  to  have  a  supplementary  list  of  foods,  usually  called  "  arti- 
cles of  special  diet,"  from  which  the  visiting  physician  or  surgeon  is 
to  select  appropriate  food  for  individual  cases.  The  expression  "  low 
diet,"  indicating  that  for  the  very  sick  patients,  is  an  unfortunate  one, 
as  it  may  have  a  depressing  sound.  In  other  institutions,  where  more 
care  is  bestowed  upon  diet,  it  is  found  both  convenient  and  practical 
to  subdivide  the  diet  under  several  additional  headings;  the  diet 
under  each  heading  to  contain  only  specially  selected  and  classified 
foods.  This  arrangement  is  to  be  highly  commended,  as  it  not  only 
saves  much  time  and  confusion,  but  is  economical  to  the  institution 
in  preventing  waste,  instead  of  sending  a  large  number  of  full  diets 
from  the  kitchen  to  the  ward,  where  the  lighter  or  more  easily  digest- 
ible articles  are  selected  for  the  sicker  patients  by  possibly  inexperi- 
enced nurses,  much  of  the  food  being  returned  uneaten.  If  the  diet 
is  assorted  in  the  kitchen  and  sent  to  the  ward  in  a  properly  classi- 
fied condition — that  is,  so  many  rations  of  each  specified  class — there 
is  very  much  less  waste  and  confusion. 

Under  this  system,  the  subdivisions  which  it  is  found  practical 
and  advantageous  to  adopt  are  the  following : 

I.  Milk  Diet,  consisting  of  from  two  and  a  half  to  three  quarts 
of  ToWk  J>er  diem,  and  nothing  else. 

II.  Convalescent  Diet,  or  half  diet,  or  light  diet,  as  it  is  vari- 
ously called,  intended  for  patients  convalescing  from  acute  disease, 
or  for  patients  who  are  unable  to  digest  the  full  house  diet.  In  the 
average  medical  ward  the  majority  of  patients  live  usually  upon 
this  diet,  which  is  not  adapted  for  the  special  requirements  of  any 
particular  disease,  but  is  simply  light,  nutritious,  and  easy  of  diges- 
tion, and  is  therefore  serviceable  in  a  very  large  number  of  cases 
which  do  not  need  more  careful  selection  of  their  food. 

III.  Farinaceous  Diet,  from  which  animal  food,  with  perhaps 


748  RATIONS,  DIETARIES. 

the  exception  of  milk  and  butter,  is  excluded.  This  diet  is  not  of 
very  general  use,  but  is  temporarily  serviceable  in  some  forms  of 
disease,  such  as  chronic  Bright's  disease  and  acute  gout. 

IV.  Nitrogenous  Diet,  or  animal  food,  which  is  somewhat  more, 
used  than  the  preceding  diet,  and  from  which  sugars  and  almost  all 
forms  of  starchy  food  excepting  a  little  dried  bread,  toast,  or  Gra- 
ham bread,  are  excluded.  This  diet  is  particularly  serviceable  in 
cases  of  flatulent  dyspepsia,  chronic  gastric  catarrh,  and  dilatation 
of  the  stomach,  in  which  the  starches  and  sugars  invariably  undergo 
acid  fermentation,  with  eructations  and  flatulence.  It  also  serves  for 
diabetics. 

V.  House  or  Full  Diet  should  be  the  most  economical  diet  for 
the  hospital  upon  which  patients  who  have  nearly  completed  their 
convalescence  may  be  placed,  as  well  as  those  patients,  including  cer- 
tain medical  cases  and  a  large  number  of  minor  surgical  cases,  whose 
digestive  organs  are  in  normal  condition.  It  usually  includes  the 
coarser  articles  of  food,  sometimes  corned  beef  and  cabbage,  pota- 
toes, codfish,  etc.,  and  it  is  very  often  the  general  diet  for  the  serv- 
ants and  attendants  in  hospitals  as  well  as  patients. 

VI.  Articles  of  Special  Diet. — Under  this  list  are  included 
luxuries  and  delicacies,  such  as  oysters,  jellies,  custards,  etc.,  and 
extra  allowances  of  eggs,  chicken,  cream,  and  fruits,  which  may  be 
desirable  to  furnish  in  a  few  individual  cases. 

With  a  system  arranged  upon  this  plan,  as  will  be  seen  by  the 
accompanying  sample  tables,  used  in  some  of  the  representative 
hospitals,  the  ordering  of  the  diet  is  simplified  for  the  visiting 
physician  or  surgeon,  and  is  much  less  apt  to  be  relegated  by  him 
to  subordinates  than  it  is  if  he  is  obliged  to  spend  the  time  required 
for  selecting  a  separate  menu  for  each  patient  in  the  ward.  The 
limitations  of  each  separate  diet  should  be  distinctly  understood  by 
all  the  attendants  and  nurses,  and  a  printed  diet  list  of  articles 
included  under  the  headings  "nitrogenous  diet,"  "farinaceous  diet," 
etc.,  should  be  conspicuously  posted  in  the  ward  dining  or  service 
rooms.  The  daily  variations  within  the  limits  of  these  diets  should 
be  regulated  by  the  superintendent  of  the  hospital  or  an  assistant, 
whose  special  duty  it  is  to  provide  the  food  for  the  institution,  and 
select  such  articles  as  will  give  reasonable  variety,  due  allowance 
being  made  for  variations  in  regard  to  price  and  season  of  the  year. 

In  many  large  hospitals  not  only  is  the  arrangement  of  the  diet 
imperfect,  but  the  details  of  preparing  and  serving  food  are  so  in- 
efficiently supervised  that  there  is  great  loss  from  waste  and  imper- 
fect cooking,  and  the  additional  expense  of  employing  one  or  two 
specially  trained  persons  to  superintend  these  matters  would  be 
more  than  counterbalanced  by  the  saving  in  the  waste  and  in  the 
benefit  to  the  patients. 


HOSPITAL   DIETARIES. 


749 


Overfeeding. — Too  much  food  is  often  given  hospital  patients 
by  overzealous  nurses,  who  are  anxious  to  hasten  convalescence. 
This  is  particularly  true  in  the  treatment  of  simple  surgical  cases 
where  there  is  no  special  digestive  disorder.  A  man  accustomed  to 
doing  eight  hours  of  active  physical  labour  when  put  to  bed  for  six 
weeks  or  more  with  his  leg  immobilised  for  a  fracture,  does  not  need 
to  be  constantly  stuiffed  with  large  quantities  of  food,  and  yet  such 
patients,  if  the  matter  is  not  carefully  directed,  will  be  often  found 
to  receive  full  house  diet,  which  in  itself  is  ample  for  the  working 
attendants  of  the  hospital,  and  in  addition  to  be  given  two  or  three 
quarts  of  milk  a  day  as  a  beverage.  The  natural  result  is  consti- 
pation, indigestion,  with  a  heavily  coated  tongue  and  more  or  less 
biliousness,  which  in  turn  is  counteracted  by  a  compound  cathartic 
pill  or  a  dose  of  calomel.  I  have  known  of  night  nurses  going 
through  wards  with  pitchers  of  milk,  and  pouring  out  tumblerfuls 
for  any  patients  who  were  at  all  thirsty,  quite  irrespective  of  any 
supervision.  In  a  large  hospital,  where  the  monthly  consumption 
of  milk  is  from  ten  thousand  to  fifteen  thousand  gallons,  it  may  be 
easily  seen  that  its  indiscriminate  use  as  a  beverage  is  an  item  of 
very  considerable  and  unnecessary  expense  to  the  institution, 
besides  being  an  actual  detriment  to  many  of  the  patients. 

AiDOther  undesirable  tendency  among  American  hospital  dietaries 
is  to  include  too  much  meat.  The  ordinary  hospital  menu  compared, 
for  instance,  with  that  of  the  agricultural  labourer,  shows  this  fact 
very  strikingly.  Certainly  not  over  four  ounces  of  cooked  meat 
(without  bone)  should  be  allowed  in  the  ration  for  men. 

"  Fish  Diet." — In  some  hospitals  in  addition  to  the  subdivisions 
of  the  diet  above  given,  a  "  fish  diet "  may  be  ordered,  which  is  very 
useful  and  should  be  generally  adopted.  In  the  London  Fever  Hos. 
pital  this  diet  consists  of  a  ration  of  bread  ten  ounces  and  fish  eight 
ounces  (the  uncooked  measure),  such  as  haddock,  cod,  or  sole  or 
some  similar  fish,  potatoes  eight  ounces,  cocoa  one  ounce,  with  half 
an  ounce  of  sugar  and  a  sixth  of  a  pint  of  milk.  This  is  a  service- 
able and  economical  form  of  diet  for  a  considerable  class  of  patients 
for  whom  large  quantities  of  meat  are  not  only  unnecessary  but  in- 
jurious. 

Broth  Diet.— In  children's  hospitals  a  diet  is  sometimes  classi- 
fied as  the  "  broth  diet,"  with  mutton  broth  flavoured  with  vegetables, 
and  bread  and  butter,  with  milk;  or  a  "beef-tea  diet,"  in  which  the 
beef  tea  replaces  the  broth  ;  and  in  the  lighter  diet  of  children,  gruels, 
bread  and  molasses,  and  simple  artices  of  farinaceous  food  such  as 
farina,  corn  starch,  rice,  etc.,  should  play  an  important  role.  Some- 
times  such  diet  goes  under  the  name  of  "  soft  food." 

In  some  of  the  English  hospitals,  as  in  the  London  Fever  Hos- 
pital, beer  is  allowed  with  the  full  diet,  and  in  this  hospital  also  a 


750 


RATIONS,   DIETARIES. 


discrimination  is  made  in  ordering  the  diet  according  to  sex,  females 
being  given  from  two  to  four  ounces  less  bread  and  two  to  three 
ounces  less  meat  than  males.  This  discrimination  is  not  usually 
made  in  American  hospitals. 

Sample  Hospital  Dietaries, 
dietary  of  the  new  york  hospital,  1895. 

"All  patients  shall  be  furnished  the  regular  house  diet,  unless 
otherwise  specially  directed  by  the  attending  physician  or  surgeon. 
As  a  substitute  for  the  house  diet,  there  may  be  furnished,  on  the 
order  of  the  attending  physician  or  surgeon  only,  either  of  the  fol- 
lowing : 

"  I.  Restricted  diet. 

"  2.  Milk  diet. 

"  The  attending  physician  or  surgeon  shall  specify,  on  the  occa- 
sion of  his  first  visit  to  a  patient,  which  diet  shall  be  furnished. 
This  duty  may  not  be  delegated  to  the  house  physician  or  house  sur- 
geon, except  that,  on  the  admission  of  a  patient  to  a  ward,  it  shall  be 
the  duty  of  either  to  give  instruction  on  the  subject  to  the  nurse  in 
charge,  and  such  instruction  shall  be  followed  until  the  first  visit  of 
the  attending  physician  or  surgeon. 

"  The  wards  shall  be  supplied  with  blanks,  called  diet  lists.  The 
head  nurse  shall  carry  one  of  these  with  her  regularly  when  accom- 
panying the  attending  physician  or  surgeon  on  his  visits,  and  shall 
note  down  carefully  all  his  instructions  as  to  diet ;  he  shall  sign 
these  lists  before  leaving  the  ward. 

"  Milk  diet,  or  restricted  diet,  may  not  be  ordered  in  addition  to 
the  regular  house  diet,  but  only  as  a  substitute  therefor,  but  the 
attending  physician  or  surgeon  may  order  items  of  special  diet  in 
particular  cases. 

"  Lists  defining  the  different  classes  of  diet  shall  be  furnished  each 
attending  physician  and  surgeon. 

"  Cards,  appropriately  inscribed,  shall  be  placed  at  the  head  of 
each  bed,  which  shall  designate  the  class  of  diet,  and  also  the  amount 
of  stimulant,  which  is  furnished  each  patient. 

"  A  diet  kitchen  is  established,  under  the  direction  and  control  of 
the  directress  of  nurses,  wherein  articles  of  special  diet  shall  be  pre- 
pared and  served  as  ordered. 

"  Daily  House  Diet. 

^^  Breakfast. — Oatmeal  or  hominy  ;  tea  or  coffee,  with  milk  and 
sugar ;  bread  and  butter. 

"  Dinner. — Potatoes  ;  bread  and  butter  ;  one  or  more  of  the  fol- 
lowing vegetables :  turnips,  sweet  potatoes,  beets,  spinach,  squash. 


HOSPITAL   DIETARIES.  75 1 

'' Supper.— T&a.  vi'iih  milk  and  sugar;  bread  and  butter;  stewed 
or  fresh  fruit. 

"/«  addition  on  Sunday. — Breakfast:  eggs.  Dinner:  roast  beef, 
corn-starch  pudding.  J/^^a'.^)'.— Breakfast :  baked  potatoes.  Din- 
ner :  stock  soup,  stewed  beef  or  mutton,  rice  pudding.     Tuesday. 

Breakfast:  Mutton  chops.  Dinner:  pea  soup,  roast  mutton,  bread 
pudding.  Wednesday.— BxtakidiSX.:  fried  or  stewed  potatoes.  Din- 
ner :  roast  beef,  corn-starch   pudding.     Thursday. Breakfast :  eggs. 

Dinner  :  stock  soup,  stewed  beef  or  mutton,  tapioca  pudding,  ^r/- 
t/ay.— Breakfast :  salt  mackerel  or  codfish.  Dinner:  bean  soup, 
baked  fish,  beans,  rice  pudding.  Saturday.— Bxtskisist:  beefsteak. 
Dinner :  corned  beef,  cabbage,  bread  pudding. 

"  J^es  trie  ted  Diet. 

''  Breakfast.— Tea.  or  coffee  (with  milk  and  sugar),  farinaceous 
food  (with  milk),  eggs. 

"Z>/««^/-.— Soup  ;  either  of  the  following  :  raw  oysters,  roast  beef, 
steak,  chicken  with  vegetables,  pudding  (bread,  rice,  tapioca,  or  corn 
starch), 

"  Supper. — Tea  (with  milk  and  sugar),  bread  (with  butter),  fruit 
(fresh  or  dried). 

"  Milk  Diet. 

"Six  pints  of  milk  daily. 

"  Articles  of  Special  Diet. 

"  Milk,  eggs,  beef  tea,  oysters,  corn  starch,  chops,  steak,  chicken, 
chicken  soup,  rice,  broth,  farina,  ice  cream,  as  ordered  by  the  attend- 
ing physician  or  surgeon. 

"Salt  fish,  jellies,  custards,  gruels." 

At  the  New  York  Hospital  a  carefully  graduated  diet  list,  made 
out  in  ounces /(?/-  capita,  was  formerly  in  use,  but  it  was  found  both  un- 
necessary and  unpractical.  Separate  tables  are  laid  for  the  patients, 
nurses,  and  servants;  but  the  amount  of  food  is  estimated  in  a  gen- 
eral way,  the  terms  being  based  rather  upon  the  cost  price /^r  capita 
than  upon  the  number  of  ounces,  and  it  is  proportioned  by  the  house- 
keeper and  her  assistants  with  due  regard  to  economy. 

DIETARY   OF   THE   PRESBYTERIAN    HOSPITAL,   NEW   YORK.    1898. 

Although  the  diet  is  very  satisfactory  and  ample  at  the  Presby- 
terian Hospital,  New  York,  the  food  allowance /<'r  capita  for  patients 
is  not  separately  estimated,  and  the  house  diet,  convalescent  diet,  and 
diet  for  the  servants  are  all  originally  prepared  in  bulk,  and  subse- 
quently subdivided  by  the  cooks  and  nurses,  under  the  order  of  the 
visiting  physicians  and  surgeons,  but  without  regard  as  to  accurate 
measurement  of  quantity  in  ounces. 
50 


752 


RATIONS,   DIETARIES. 


House  Diet. 

Convalescent  Diet. 

Nitrogenous  Diet. 

BREAKFAST. 

BREAKFAST. 

BREAKFAST. 

Tea   or  coffee   (milk  and 

Tea   or  coffee  (milk  and 

Tea  or  coffee  (milk 

sugar). 

sugar). 

Bread  and  butter — 

Bread  and  butter — 

Bread  and  butter — 

Graham  bread. 

White  bread,  or 

White  bread,  or 

Graham  bread,  or 

Graham  bread,  or 

Corn  bread,  or 

Corn  bread,  or 

Rolls,  or  Toast. 

Rolls,  or  Toast. 

Porridge — 

Porridge — 

Oatmeal,  or 

Hominy,  or 

Wheaten  grits,  or 

Farina. 

Indian  meal,  or 

Hominy,  or 

• 

Farina,  or  Samp. 

Meats — 

Meats — 

Meats — 

Hash,  or 

Eggs,  or 

Eggs,  or 

Eggs,  or 

Fresh  fish,  or 

Fresh  fish,  or 

Salt  fish,  or 

Stew  (plain). 

Stew   without  vegeta- 

Fresh fish,  or 

bles,  or 

Stew. 

Meat  hash  without  po- 
tatoes. 

DINNER. 

DINNER. 

DINNER. 

Soup — 

Soup — 

Soup — 

Stock,  or 

Stock,  or 

Stock,  or 

Mutton  broth,  with  bar- 

Chicken, or 

Chowder. 

ley  or  vegetable,  or 

Mutton  broth,  with  bar- 

Chowder. 

ley  or  vegetable. 

Dry  bread. 

Dry  bread. 

Graham  bread. 

Meats- 

Meats — 

Meats — 

Beef  (roast  or  boiled),  or 

Beef  (roast  or  boiled),  or 

Beef  (roast  or  boiled),  or 

Mutton  (roast  or  boiled),  or 

Chicken,  or 

Mutton(roastorboiled),or 

Corned  beef,  or 

Fish  (fresh). 

Fresh  fish,  or 

Fresh  fish,  or 

Irish  stew. 

Irish  stew. 

Vegetables — 

V^etables — 

Vegetables — 

Potatoes,  baked,  boiled. 

Potatoes  (baked),  or 

Spinach,  or 

or  mashed,  and 

Rice,  or 

Lettuce,  or 

Tomatoes,  or 

Macaroni,  or 

Celery,  or 

Baked  beans,  or 

Samp. 

String  beans. 

French  beans,  or 

Turnips,  or 

Beets,  or 

Rice,  or 

Macaroni,  or  Samp. 

Pudding — 

Pudding — 

Pudding — 

Rice,  or 

Rice  or 

Custard. 

Bread,  or 

Bread,  or 

Tapioca,  or 

Tapioca,  or 

Farina,  or 

Farina,  or 

Corn  starch,  or  Custard. 

Com  starch,  or  Custard. 

SUPPER. 

SUPPER. 

SUPPER. 

Tea  (sugar  and  milk). 

Tea  (milk  and  sugar). 

Tea  (milk). 

Bread  and  butter,  or 

Bread  and  milk,  or 

Graham  bread  and  but- 

Toast and  butter. 

Milk  toast,  or 

ter,  or 

Bread  and  butter,  or 

Bread  and  milk. 

Toast  and  butter. 

Eggs,  or 

Fruit — 

Fruit — 

Cold  meat. 

Apples,  stewed  or  baked,  or 

Apples,  stewed  or  baked,  or 

Prunes,  or  Pears. 

Prunes,  or  Pears. 

HOSPITAL   DIETARIES. 


753 


Farinaceous  Diet. 

Milk  Diet. 

Extras. 

BREAKFAST, 

BREAKFAST. 

ORDERED   ONLY   BY  THE 

Tea   or   coffee   (milk   and 

One  quart  of  milk. 

ATTENDING  PHYSICIAN 

sugar). 

OR   SURGEON. 

Bread  and  butter — 

Mutton  chops. 

White  bread,  or 

Beefsteak. 

Graham  bread,  or 

Scraped  beef. 

Com  bread,  or 

Beef  tea  (made  with  hy- 

Rolls, or 

drochloric  acid). 

Toast. 

Chicken   (broiled,   fricas- 

Porridge— 

seed,  or  roast). 

Hominy,  or 

Chicken  broth. 

Farina,  or 

Eggs. 

Indian  meal. 

Milk. 
Oysters. 
Clam  broth. 
Gruels. 
Crackers. 
Gingerbread. 
Custard. 
Milk  toast. 

DINNER. 

DINNER. 

Soup — 

One  quart  of  milk. 

Vegetable,  or 

Macaroni,  or 

Barley  broth. 

Dry  bread. 

Vegetables — 

Baked  potatoes  and 

Tomatoes,  or 

French  beans,  or 

Rice,  or 

Macaroni,  or 

Samp. 

Pudding — 

Rice,  or 

■RrpnH,  or 

Tapioca,  or 
Farina,  or 
Comslarch. 


SUPPER. 
Tea  (milk  and  sugar). 

Bread  and  milk,  or 

Milk  toast,  or 

Hominy,  or 

Boiled  rice,  or  Farina. 
Fruit — 

Apples  stewed  or  baked,  or 

Prunes,  or  Pears. 


SUPPER. 
One  quart  of  milk. 


754 


RATIONS,   DIETARIES. 


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HOSPITAL   DIETARIES. 


755 


The  foregoing  is  a  copy  of  the  diet  sheet  in  daily  use  in  the 
wards  at  the  Presbyterian  Hospital,  New  York  city.  It  will  be 
observed  that  it  is  properly  classified  according  to  quality  as  well  as 
quantity.  It  was  introduced  several  years  ago  after  a  careful  com- 
parison with  diets  of  other  institutions,  and  it  has  proved  very  prac- 
tical. It  is  the  most  liberal  and  best-classified  diet  of  any  hospital 
with  which  I  am  familiar. 

DIETARY    IX    BELLEVUE,   GOUVERNEUR,   FORDHAM,   AND 
HARLEM    HOSPITALS,   NEW   YORK,    1897. 

Monday. 

Breakfast. — Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half 
an  ounce  of  sugar ;  bread,  five  and  one  third  ounces,  and  a  quarter 
of  an  ounce  of  butter  ;  oatmeal,  one  ounce  ;  crackers,  one  ounce ; 
milk,  one  quart. 

Dinner. — Roast  beef,  eight  ounces ;  rice,  one  ounce ;  soup,  one 
pint;  potatoes,  eight  ounces;  vegetables,  four  ounces;  bread. 

Supper. — Tea,  one  pint,  with  half  an  ounce  of  milk  and  half  an 
ounce  of  sugar;  five  and  one  third  ounces  of  bread  and  a  quarter  of 
an  ounce  of  butter  ;  one  ounce  of  stewed  apples. 

Tuesday. 

Breakfast. — Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half 
an  ounce  of  sugar;  bread,  five  and  one  third  ounces,  and  a  quar- 
ter of  an  ounce  of  butter ;  hominy,  one  ounce;  crackers,  one  ounce; 
milk,  one  quart. 

Dinner. — Mutton  stew,  eight  ounces ;  potatoes,  eight  ounces ; 
vegetables,  four  ounces ;  bread,  five  and  one  third  ounces ;  bread 
pudding,  two  and  a  half  ounces. 

Supper. Tea,  one  pint,  with  half  an  ounce  of  milk  and  half  an 

ounce  of  sugar  ;  bread,  five  and  one  third  ounces  ;  butter,  a  quarter 

of  an  ounce. 

Wednesday. 

Breakfast.— Cofi€:t,  one  pint,  with  half  an  ounce  of  milk  and  half 
an  ounce  of  sugar  ;  five  and  one  third  ounces  of  bread  and  a  quarter 
of  an  ounce  of  butter;  rice,  one  ounce;  crackers,  one  ounce;  milk, 
one  quart. 

X)/>///<T.— Roast  beef,  eight  ounces  ;  barley  soup,  one  pint ;  pota- 
toes, eight  ounces  ;  bread,  five  and  one  third  ounces. 

Supper.— Ttdiy  one  pint,  with  half  an  ounce  of  milk  and  half  an 
ounce  of  sugar  ;  bread,  five  and  one  third  ounces,  and  a  quarter  of 
an  ounce  of  butter  ;  stewed  prunes,  one  ounce. 


756  RATIONS,   DIETARIES. 

Thursday. 

Breakfast. — Coffee,  one  pint,  with  half  a  pint  of  milk  and  half  an 
ounce  of  sugar ;  five  and  one  third  ounces  of  bread  and  a  quarter  of 
an  ounce  of  butter  ;  oatmeal,  one  ounce  ;  crackers,  one  ounce;  milk, 
one  quart. 

Dinner. — Beef  stew,  eight  ounces  ;  potatoes,  eight  ounces  ;  vege- 
tables, four  ounces ;  bread,  five  and  one  third  ounces. 

Supper. — Tea,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce 
of  sugar  ;  five  and  one  third  ounces  of  bread  and  a  quarter  of  an 
ounce  of  butter ;  one  ounce  of  stewed  apples. 

Friday. 

Breakfast. — Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half 
an  ounce  of  sugar  ;  five  and  one  third  ounces  of  bread  and  a  quar- 
ter of  an  ounce  of  butter  ;  two  eggs ;  crackers,  one  ounce ;  milk, 
one  quart. 

Dinner. — Baked  fish,  eight  ounces ;  potatoes,  eight  ounces ;  vege- 
tables, four  ounces  ;  bread,  five  and  one  third  ounces  ;  rice  pudding, 
two  and  a  half  ounces. 

Supper. — Tea,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce 
of  sugar  ;  five  and  one  third  ounces  of  bread  and  a  quarter  of  an 
ounce  of  butter. 

Saturday. 

Breakfast. — Coffee,  one  pint,  with  a  quarter  of  a  pint  of  milk  and 
a  quarter  of  an  ounce  of  sugar;  five  and  one  third  ounces  of  bread 
and  a  quarter  of  an  ounce  of  butter  ;  hominy,  one  ounce  ;  crackers, 
one  ounce  ;  milk,  one  quart. 

Dinner. — Mutton  stew,  eight  ounces;  potatoes,  nine  ounces; 
vegetables,  four  ounces;  bread,  five  and  one  third  ounces. 

Supper. — Tea,  one  pint,  with  milk  half  a  pint,  and  half  an  ounce 
of  sugar ;  bread,  five  and  one  third  ounces ;  butter,  a  quarter  of  an 
ounce  ;  stewed  prunes,  one  ounce. 

Sunday. 

Breakfast. — Coffee,  one  pint,  with  half  a  pint  of  milk  and  half  an 
ounce  of  sugar  ;  five  and  one  third  ounces  of  bread  and  a  quarter  of 
an  ounce  of  butter  ;  crackers,  one  ounce ;  milk,  one  quart ;  two  eggs. 

Dinner. — Corned  beef,  eight  ounces ;  bean  soup,  one  pint ;  pota- 
toes, eight  ounces ;  bread,  five  and  one  third  ounces  ;  cornstarch 
pudding,  two  and  a  half  ounces. 

Supper. — Tea,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce 
of  sugar ;  bread,  five  and  one  third  ounces,  and  butter,  a  quarter  of 
an  ounce. 


HOSPITAL   DIETARIES.  757 

Milk  Diet. 
To  be  prescribed  by  attending  physicians  or  surgeons. 

Articles  of  Special  Diet. 
Beefsteak,   half  a  pound;    beef  tea,   one  pint;   chicken,  half  a 
pound;  chicken  soup,  one  pint ;  rice  and  milk,  one  pint ;  two  eggs; 
milk,  one  quart. 

DIETARY   OF   THE    ROOSEVELT   HOSPITAL.  NEW   YORK.   1895. 

The  ward  diet  of  the  Roosevelt  Hospital,  New  York  city,. is 
classified  as  follows  : 

Full  Diet. 

Daily.— Meat,  dressed,  eight  ounces;  potatoes,  eight  ounces; 
bread,  twelve  ounces;  butter,  one  ounce;  sugar,  two  ounces  and  a 
half  ;  milk,  half  a  pint ;  coffee,  half  an  ounce  ;  tea,  an  eighth  of  an 
ounce.  On  Sundays,  Tuesdays,  and  Thursdays  other  vegetables  in 
addition  to  potatoes,  two  ounces ;  bread,  rice,  or  tapioca  pudding. 
On  Mondays  and  Wednesdays,  soup,  one  pint.     On  Fridays,  fish. 

Breakfast. — Coffee  with  sugar  and  milk,  bread  and  butter,  por- 
ridge of  oatmeal,  wheaten  grits,  or  samp. 

Dinner. — Sunday  :  Roast  beef,  potatoes,  tomatoes,  or  other  vege- 
table, bread,  and  bread  pudding.  Monday  :  Soup,  boiled  mutton, 
potatoes,  and  bread.  Tuesday:  Corned  beef,  twelve  ounces;  cab- 
bage or  turnips,  potatoes  and  bread.  Wednesday :  Soup,  roast  beef, 
potatoes,  and  bread.  Thursday  :  Soup,  boiled  beef,  potatoes,  onions, 
tapioca,  sago,  or  farina  pudding,  and  bread.  Friday:  Fish,  boiled  or 
roast  beef,  potatoes,  bread,  boiled  rice  sweetened  with  sugar  and 
milk,  and  raisins.     Saturday  :  Stew  of  mutton,  potatoes,  and  bread. 

Supper. — Tea  with  sugar  and  milk,  bread  and  butter,  baked 
apples,  or  stewed  pears,  or  prunes,  or  green  or  dried  apple  sauce, 
and,  on  Sundays,  gingerbread  varied,  alternate  weeks,  with  currant 
buns. 

Half  Diet. 

Daily. — Meat,  dressed,  four  ounces ;  potatoes,  four  ounces ;  bread, 
six  ounces ;  of  other  articles,  the  same  as  in  full  diet. 

Milk  Diet. 
Daily. — Milk,   two    pints ;  bread,  twelve   ounces ;  rice   or   samp, 
two  ounces;  butter,  one  ounce. 

Extras. 
In  addition  to  the  above,  the  following  extras  may  be  ordered  by 
the  visiting  physicians  and  surgeons:  Beefsteak,  chicken  soup,  gruel, 
beef  tea,  oysters   or   clams,  cornstarch,  mutton    chops,  milk,  rice, 
chicken,  eggs. 


758 


RATIONS,   DIETARIES. 


DIETARY   OF   THE   JOHNS   HOPKINS   HOSPITAL,   BALTIMORE. 

At  the  Johns  Hopkins  Hospital  the  Free  Ward  Diet  is  liberal, 
but  no  attempt  is  made  to  classify  the  food  qualitatively  as  served 
to  the  wards.  A  sample  Sunday  menu  given  there  is  the  following. 
It  is  expensive,  owing  to  the  excess  of  animal  food : 

^^ Breakfast. — Corned-beef  hash,  oatmeal,  toast,  eggs,  bread  and 
butter,  coffee  or  tea,  and  milk. 

'^'■Dinner. — Soup,  roast  beef,  potatoes,  rice,  turnips,  toast,  pua- 
ding  and  milk,  bread  and  butter. 

'■'■Supper. — Cold  roast  beef  or  pressed  corn  beef,  bread  and  butter, 
coffee  or  tea,  and  milk." 


DIETARY   OF   THE   COOK   COUNTY   HOSPITAL,   CHICAGO. 
In  the  Cook  County  Hospital,  of  Chicago,  the  official  diets  are 
four — viz.,  ward  diet,  light  diet,  special  diet,  milk  diet. 

Extras  may  be  ordered,  such  as  chickens,  chops,  beefsteak,  eggs, 
cream,  crackers,  lemons,  or  additional  butter,  milk,  sugar,  sirup,  and 
vinegar. 

Here  again  no  special  attempt  is  made  to  classify  foods  quali- 
tatively. 

DIETARY   FOR   LIVERPOOL   INFIRMARY. 

Sample  Diet  suggested  for  the  Liverpool  Infirmary  and  other  English 

Hospitals. 


Sick. 

Normal. 

Convalescence. 

Breakfast, 
8 .  30  A.  M. 

\  pt.  milk. 

3  oz.  bread  or  oatmeal. 

f  pt.  of  new  milk. 
6  oz.  bread. 
2  oz.  oatmeal. 

I  pt.  new  milk. 
8  oz.  bread. 
3  oz.  oatmeal. 

If  cocoa  or  coflfee  is  given  with  sugar,  omit  the  oatmeal  and  give  \  pt. 
of  milk. 

Dinner, 
1 .  30  P.  M. 

•J  pt.  of  milk,  made  into 
pudding  with  rice,  sago, 
etc. 

\  pt.  beef  tea. 

4  oz.  bread. 

Meat,  4  oz.  (men). 

"      3  oz.  (women). 
Bread,  6  oz. 
Potato,  8  o^. 
Cheese,  \  oz. 

Meat,  4  oz. 
"      3  oz. 
Bread,  8  oz. 
Potato,  8  oz. 
Cheese,  i  oz. 

Same  for  all  as  the  breakfast,  but  with  addition  of  a  cereal. 

Supper, 

6.30  to  7  P.M. 

f   pt.   broth   with    boiled 

meat. 
Salt  ad  libitum. 

Bed  at  8  P.  M, 

Malt  liquor  as  exceptional  treat. 

Total  bread,  18  oz.                Total    bread. 

24  oz. 

DIETARY  OF  THE  NEW  YORK  INFIRMARY  FOR  WOMEN  AND 

CHILDREN. 

The  following  is  a  sample  midsummer  diet,  from  a  smaller  hos- 
pital, having  about  seventy  beds,  in  which  attention  is  economically 


HOSPITAL   DIETARIES. 


759 


given  to  variety  in  food  cookery  which  would  be  impossible  in  a  larger 

institution  without  incurring  needless  expense  : 

Ward  Dietary  of  the  New  York  Infirmary  for  Women  and  Children,  iSgj. 

Breakfast. 
Hominy,  fish,  bread  and  butter,  coffee. 


Full  diets. 


Half  diets. 

Special  diets. 
Children. 


Full  diets. 


Half  diets. 

Special  diets. 
Children. 


Full  diets. 


Half  diets. 

Special  diets. 
Children. 


Hominy,  bread,  milk,  oranges. 

Dinner. 
Soup,  chicken,  rice,  squash,  hot  tapioca  pudding  with  sauce. 

Veal  broth,  rice,  chicken,  toast,  pudding. 
Chicken,  sweet  potatoes. 

Supper. 
Macaroni  with  tomato,  bread  and  butter,  tea,  peaches. 

Hominy,  tea,  peaches,  toast. 
Hominy,  bread  and  milk,  peaches. 


Average  Daily  Dietary  for  Adult   Women  Patients,  iSgj,  not  including 
Milk,  Eggs,  or  Beef  Tea  for  Special  Cases. 

Flour,  meal,  rice,  or  beans,  uncooked \  ounce. 

Bread 8    ounces. 

Butter  and  fat 2^      " 

Sugar 2        " 

Breakfast  cereals,  uncooked i    ounce. 

Meat  or  fish,  dressed  but  uncooked 8    ounces. 

Potatoes,  dressed  but  uncooked 5  to  6        " 

Fresh  or  canned  vegetables,  cooked 4  to  5        " 

Stewed  or  fresh  fruit,  prepared  or  cooked 3  to  4        " 

Soup '. ^  pint  or    8        " 

Milk I     "  "16 

Coffee i    "  "     8 

Tea  or  cocoa J     "  "     8        " 

Eggs,  one  every  day \  ounce. 

NEW   YORK   STATE    HOSPITAL.— PROPOSED   DIETARY. 

Austin  Flint  recommends  the  following  dietary  and  food  supply 
for  the  New  York  State  Hospital : 

"The  table  is  intended  for  patients  not  upon  extra  diet  and 
attendants  only,  and. I  have  suggested  that  25  per  cent  in  the  rations 
of  meat,  flour,  and  potatoes  be  added  for  workers." 


^6o  RATIONS,   DIETARIES. 

Daily  Ration. 

Meat,  with  bone,  including  salted  meats,  fresh  and  salted 

fish,  and  poultry 12  ounces. 

Flour,  to  be  used  in  making  bread  and  in  cooking  (may  in 

part  be  substituted  by  corn  meal  and  macaroni) 12  " 

Potatoes 12  " 

Milk '. 16  " 

One  egg 2  " 

Sugar 2  " 

Butter 2  " 

Cheese i  ounce. 

Rice,  hominy,  or  oatmeal \\  " 

Beans  or  peas  (dried) i^  " 

Coffee  (in  the  berry  and  roasted) ^  " 

Tea  (black) i  " 

Supplies  for  One  Hundred  Persons  for  Thirty  Days. 

Meat,  with  bone,  including  salted  meat,  fresh  and  salted 

fish,  and  poultry,  total 2,250  pounds. 

Flour  (may  be  in  part  substituted  by  com  meal  and  mac- 
aroni)   2,250       " 

Potatoes 2,250       " 

Milk 1.500  quarts. 

Eggs 250  dozen. 

Sugar 490  pounds. 

Butter « 430       " 

Cheese 215       " 

Rice 108       " 

Hominy 108       " 

Oatmeal , 108       " 

Coffee 180      " 

Tea 26      " 

"  Flour  should  be  interchangeable,  on  this  basis,  with  potatoes, 
rice,  hominy,  and  oatmeal.  Butter  and  cheese  may  be  interchange- 
able in  the  proportion  of  one  pound  of  butter  to  two  pounds  of 
cheese;  and  eggs  and  milk,  in  the  proportion  of  two  eggs  to  one 
pint  of  milk.  There  are  occasions  when  eggs  may  be  substituted 
with  advantage  for  meat.  This  may  be  done  on  the  basis  of  eight 
eggs  for  one  pound  of  meat.  When  fruits,  fresh  and  dried,  are  used  in 
abundance,  a  reduction  may  be  made  in  eggs,  butter,  cheese,  and  milk." 

DIETARY   OF   THE   UTICA   STATE    HOSPITAL   FOR   THE   INSANE, 

1894. 

Monday. 

Breakfast. — Cold  corned  beef,  oatmeal,  boiled  potatoes,  bread  and 
butter,  tea  or  coffee. 

Dinner. — Roast  beef,  boiled  potatoes,  gravy,  boiled  rice,  bread 
and  butter,  tea. 

Supper. — Roll,  bread,  sirup,  butter,  tea. 


HOSPITAL   DIETARIES. 


761 


Tuesday. 

Breakfast. — Cold  roast  beef,  oatmeal,  boiled  potatoes,  bread  and 
butter,  tea  or  coffee. 

Dinner. — Vegetable  soup,  boiled  mutton,  boiled  potatoes,  bread 
and  butter,  and  tea. 

Supper. — Molasses  cookies,  bread  and  butter,  tea. 

Wednesday. 

Breakfast. — Roast  mutton,  oatmeal,  boiled  potatoes,  bread  and 
butter,  tea  or  coffee. 

Dinner. — Roast  veal,  boiled  potatoes,  Indian  pudding,  gravy, 
bread  and  butter,  tea. 

Supper. — Stewed  prunes,  bread  and  butter,  tea. 

Thursday. 

Breakfast. — Cold  roast  veal,  oatmeal,  boiled  potatoes,  bread  and 
butter,  tea  or  coffee. 

Dinner. — Baked  salt  pork,  baked  beans,  boiled  potatoes,  bread 
and  butter,  tea. 

Supper. — Cheese,  roll,  bread,  sirup,  butter,  tea. 

Friday. 

Breakfast. — Codfish,  oatmeal,  boiled  potatoes,  bread  and  butter, 
tea  or  coffee. 

Dinner. — Fresh  fish,  boiled  potatoes,  dried  raspberry  pie,  bread 
and  butter,  tea. 

Supper. — Sugar  cookies,  bread  and  butter,  tea. 

Saturday. 

Breakfast. — Cold  roast  beef,  oatmeal,  boiled  potatoes,  bread  and 
butter,  tea  or  coffee. 

Dinner. — Corned  beef,  boiled  cabbage,  boiled  potatoes,  bread  and 
butter,  tea. 

Supper. — Corn  and  wheat  bread,  cheese,  butter,  tea. 

Sunday. 

Breakfast. — Boiled  eggs,  oatmeal,  boiled  potatoes,  bread  and  but- 
ter, tea  or  coffee. 

Dinner.— Zo\^  boiled  ham,  boiled  potatoes,  pickled  beets,  canned 
corn,  bread  and  butter,  tea. 

Supper. — Ginger  cookies,  bread  and  butter,  tea. 

Fresh  vegetables  and  fruits  in  their  season. 

Extra  diet  may  be  ordered  as  follows:  Milk  toast,  dry  toast,  egg 
on  toast,  beef  tea,  beefsteak,  chops,  ham,  scrambled  eggs,  fried  and 


762 


RATIONS,    DIETARIES. 


boiled  eggs,  baked  custard,  cornstarch,  rice  and  milk,  gruel,  sauce, 
hot  milk,  and  chocolate.     For  each  patient  the  daily  allowance  is : 

Butter i^  oz. 

Sugar i^  " 

Potatoes iif  " 

Coffee 1%  " 

Tea I" 

Flour iii  " 

Fresh  beef. 10    " 

Fresh  vegetables  in  season  and  in  varying  amount. 

Extra  Diet. 

{  Milk  toast  (for  breakfast)  )  „,  .  , 

T,     r        ,^Vi  .       ^      ^\  \  Three  times  a  day. 
I  Beef  tea  (Cybils  s  extract)  ) 

j  Gruel  (at  night). 

(^  Milk  (about  three  quarts  daily). 

(-Breakfast— Egg  on  toast  (no  coffee. 

\  Dinner — Steak  (rare)  or  chops,  fresh  vegetables. 

I  Supper — Gruel,  sauce  (apple),  custard  or  boiled  egg, 

'  Milk,  one  quart. 

Three  eggs. 

Cod-liver  oil. 

Whiskey. 


Acute  mania. 


Melancholia. 


Melancholia,  re- 
fusing food  fed     ,, 

"  <  Sugar, 

by  tube    twice 

daily. 


Salt. 

Pancreatin,  three  grains. 
Pepsin,  three  grains. 
[  Sodium  bicarbonate,  fifteen  grains. 

This  amount  given  twice  a  day  is  varied  once  a  week  by  chicken 
or  mutton  broth. 

**  Two  of  the  patients  have  been  fed  by  tube  with  this  combina- 
tion for  over  a  year,  and  both  are  in  good  condition."     (Dr.  Steele.) 
Full  Dietaries  for  Children  at  Various  English  Hospitals  (Chambers). 


Age. 

Bread. 

Butter. 

Milk. 

Meat. 

Vegeta- 
bles. 

Under  7. 
Under  7. 

Un- 
limited. 
12  oz. 

I  oz. 

? 

ipt. 
ipt. 

2  OZ. 

2  OZ. 

4  OZ. 

3  oz. 

Under  8. 

5ioz. 

About 
f  oz. 

ipt. 

2  OZ. 

4  oz. 

Under  8. 

8  oz. 

About 

? 

2  OZ. 

4  oz. 

Above  8. 
Under  9. 

8  oz. 
6  oz. 

I  oz. 

About 

I  oz. 

? 

ipt. 
ipt. 

3  OZ. 

broth, 
ipt. 

2  OZ. 

6  oz. 
6  oz. 

Under   9. 
Under  10. 
Under  10. 

7  oz. 
12  oz. 
6  oz. 

\  oz. 
f  oz. 

? 

ipt. 
ipt. 
lipt. 

4  OZ. 

2  OZ. 

2  eggs. 

4  oz. 
4  oz. 

? 

Pudding. 


Hospital. 


Twice 
a  week, 
i  pint. 


Unlimited.!  St.  George's. 


Gruel, 
i  pint. 

i  pint  gruel 
or  broth. 
To  order. 

6  oz. 

8  oz. 


London. 

Children's  Hospital, 
Great  Ormond  Street, 
and  Evelina  Hospi- 
tals. 

Leeds  Infirmary. 

Children's,  Great  Or- 
mond Street,  and 
Evelina  Hospitals. 

Birmingham  General 
Hospital. 

St.  Bartholomew's. 

St.  Thomas's. 

King's  College. 


DIETARIES   OF   ARMY   HOSPITALS. 
Diet  of  Northeastern  Hospital  for  Children,  London. 


763 


Milk  diet. 

Fish  diet. 

Full  diet. 

Breakfast,  7  A.  M. . . . 

Milk,  i  pt.  ;  bread. 

Milk  or  cocoa,  Apt.; 

Milk  or  cocoa,  \  pt. ; 

2  oz.,  with  butter. 

bread,  2^02.,  with 

bread,   i\  oz.,  with 

butter. 

butter. 

Dinner,  12  m 

Milk, -J-  pt.  ;  rice  or 

Fish,  boiled,  2A  oz. ; 

Roast,  boil'd,  or  minc'd 

other    milk    pud- 

potatoes, mashed. 

mutton,  or   roast  or 

ding. 

3    oz  ;    bread,    i 

minced  beef,  i\  oz. ; 

oz.  ;    milk     pud- 

mashed  potatoes,   4 

ding. 

oz.,  to  alternate  with 
green       vegetables ; 
bread,    i    oz.  ;    milk 
pudding. 

Tea,  3.30  p.  M 

Milk,  -^t. ;  bread, 

Milk,  \  pt. ;  bread. 

Bread,  2^  oz..  with  but- 

2 OZ.,  with  butter. 

2-J  oz.,  with  trea- 

ter, treacle,  or  drip- 

cle  or  butter. 

pint^s  ;  milk,  \  pt. 

Supper,  6  p.  M 

Biscuit  (cracker)  or 

Bread,   2    oz.,  with 

Bread,  2  oz.,  with  but- 

slice of  bread  and 

butter,  or  cracker. 

ter,  or  cracker. 

butter. 

DIETARIES  OF  ARMY  HOSPITALS. 

United  States  Army  Hospitals. 

Special  Diet.. — The  medical  officer  will  select  from  this  list 
according  to  his  discretion  :  Bread,  butter,  coffee,  tea,  toast  (dry), 
toast  (milk),  eggs  (boiled),  eggs  (poached),  milk,  beefsteak,  milk 
porridge,  ham,  beef  extract,  oatmeal  mush  and  milk,  chicken  (stewed), 
chicken  broth,  mutton  chop,  mutton  broth,  chocolate,  oysters 
(stewed),  beef  tea,  rice  (boiled),  farina  pudding,  cornstarch,  crackers 
(soda  or  cream),  potatoes  (baked),  potatoes  (mashed),  beef  essence, 
macaroni  (boiled),  canned  peaches  (stewed),  canned  apples  (stewed), 
canned  pears,  grapes,  oranges,  lemons,  apples,  watermelons,  canta- 
loupes, etc. 

The  following  comprises  the  list  of  articles  allowed  in  the  ration 
of  the  U.  S.  Army  post  hospitals: 

Breakfast. 

Bread 6  ounces. 

Butter i  ounce. 

Coffee I  pint- 
Tea  I     " 

Toast,  dry 4  ounces. 

Toast,  milk " 

Eggs,  boiled * 

Eggs,  poached * 

j^iljj 12  ounces. 

Beefsteak ^ 

Milk  porridge '  P'"'- 

Ham 4ounces. 

Beef  essence 2 


jrg^  RATIONS,   DIETARIES. 

Dinner. 

Bread 4  ounces. 

Chicken,  stewed 6       " 

Chicken  broth i  pint. 

Mutton  chop 6  ounces. 

Mutton  broth i  pint. 

Milk .' 12  ounces. 

Oysters,  stewed i  gill. 

Beef  tea I2  ounces. 

Rice,  boiled i  ounce. 

Farina  pudding 4  ounces. 

Cornstarch  pudding 4       " 

Milk  porridge i  pint. 

Beefsteak ^ 6  ounces. 

Potatoes,  mashed 6       " 

Beef  essence 2      " 

Supper. 

Tea I  pint. 

Butter i  ounce. 

Bread 4  ounces. 

Toast,  dry 4 

Milk 12      " 

Eggs I 

Milk  porridge i  pint. 

Beef  essence 2  ounces. 

British  Army  Hospitals. 

The  following  statement  is  quoted  from  a  report  made  by  Col. 
Alfred  A.  Woodhull,  M.  D.,  LL.  D.,  recently  sent  abroad  by  the 
U.  S.  Army  Department  to  investigate  certain  medical  features  of  the 
British  army  : 

"  The  British  army  uses  seven  [diets],  known  as  tea,  milk,  beef  tea, 
chicken,  convalescent,  roast,  and  varied.  Each  is  formulated  with 
exactness,  and  parts  of  two  diets  may  not  be  ordered  together.  The 
tea  diet  is:  Bread,  twelve  ounces;  tea,  half  an  ounce;  sugar,  two 
and  a  half  ounces;  milk,  six  ounces.  The  varied  diet  is:  Beef  or 
mutton,  twelve  ounces  without,  or  fifteen  ounces  with  bone;  bread, 
eighteen  ounces;  tea,  half  an  ounce;  sugar,  one  and  a  half  ounce; 
milk,  six  ounces ;  butter,  one  ounce;  potatoes,  sixteen  ounces; 
vegetables,  four  ounces,  with  salt,  pepper,  and  mustard,  and  option- 
ally wine,  spirits,  malt  liquors,  and  diet  drinks  may  be  ordered. 
These  diets  represent  the  extremities  of  the  scale  through  which  the 
others  run.  The  ordinary  drinks  allowed  for  patients  are :  Barley 
water,  rice  water,  gruel,  and  lemonade,  each  prepared  by  formula." 

Prussian  Army  Hospitals. 
According  to  Roth  and  Lex,  in  four  grades  of  diet  in  Prussian 
military  hospitals  the  proportionate  allowance  of  food  classes  is  as 
follows: 


DIETARIES   OF   ARMY   HOSPITALS. 


765 


Albumin 

Fat 

Carbohydrates 


I. 

II. 

III. 

IV. 

"5 

81 

52 

18 

55 

39 

32 

15 

522 

315 

179 

127 

French  Army   Hospitals. 

Kirchner  gives  the  following  analysis  of  the  nutrient  ingredients 
of  the  seven  different  classes  into  which  diet  in  the  French  military 
hospitals  is  divided.  "  Absolute  diet  "  {dihe  absolue)  is  practical  star- 
vation, at  most,  only  a  little  toast  water  being  given,  and  is  of  serv- 
ice for  such  cases  as  may  require  exclusive  rectal  feeding. 


Full  diet 

f  diet 

i    "    

i    "    

i    "    

Bread  diet. . . 
Absolute  diet 


Albumin. 


Grammes. 
119 

70 

35 
19 
14 


Fat. 


Grammes. 

57 
47 
39 
25 
17 
36 


Carbohydrates. 


Grammes. 
448 

357 
225 

134 
89 
89 


APPENDIX. 


RECEIPTS  FOR  INVALID  FOOD  AND  BEVERAGES, 
SUITABLE  FOR  FEVERS  AND  CONVALESCENCE 
FROM   ACUTE   ILLNESS. 


BEVERAGES. 

i:  Demulcent  and  Nutritive. 

Barley  Water  (Pavy). — Take  two  ounces  of  pearl  barley  and 
wash  well  with  cold  water,  rejecting  the  washings.  Afterwards  boil 
with  a  pint  and  a  half  of  water  for  twenty  minutes  in  a  covered  ves- 
sel, and  strain.  The  product  may  be  sweetened  and  flavoured  with 
lemon  peel,  or  lemon  peel  may  be  introduced  while  boiling  is  carried 
on.  Lemon  juice  is  also  sometimes  added  to  flavour.  A  bland,  de- 
mulcent, and  mildly  nutritive  beverage. 

Barley  Water  {Bartholow). — Wash  two  ounces  of  pearl  barley 
with  cold  water.  Then  boil  it  for  five  minutes  in  some  fresh  water, 
and  throw  both  waters  away.  Then  pour  on  two  quarts  of  boiling 
water,  and  boil  it  down  to  a  quart.  (Stir  and  skim  occasionally.) 
Flavour  with  thinly  cut  lemon  rind ;  add  sugar  to  taste,  but  do  not 
strain  unless  at  the  patient's  request. 

Barley  Water  {Ringer). — To  a  tablespoonful  of  pearl  barley 
washed  in  cold  water  add  two  or  three  lumps  of  sugar,  the  rind  of 
one  lemon,  and  the  juice  of  half  a  lemon.  On  these  pour  a  quart  of 
boiling  water,  and  let  the  mixture  stand  for  seven  or  eight  hours. 
Strain.  The  barley  water  should  never  be  used  a  second  time.  Half 
an  ounce  of  isinglass  may  be  boiled  in  the  water.  If  not  needed  at 
once,  these  barley  preparations  should  be  kept  in  the  refrigerator 
and  warmed  when  required. 

Rice  Water  or  Mucilage  of  Rice  (/*a?y).— Thoroughly  wash 
one  ounce  of  rice  with  cold  water.  Then  macerate  for  three  hours 
in  a  quart  of  water  kept  at  a  tepid  heat,  and  afterwards  boil  slowly 
for  an  hour,  and  strain.  A  useful  drink  in  dysentery,  diarrhoea,  and 
irritable  states  of  the  alimentary  canal.  It  may  be  sweetened  and 
flavoured  in  the  same  way  as  barley  water. 
51  767 


-58  APPENDIX. 

Demulcent  Drink  {Rifiger). — Take  a  pinch  of  isinglass,  and  boil 
it  in  half  a  pint  of  new  milk  with  half  a  dozen  bruised  sweet  almonds 
and  three  lumps  of  sugar. 

Linseed  Tea  {Chambers). — Whole  linseed,  white  sugar,  each  one 
ounce  ;  licorice  root;  one  half  ounce  ;  lemon  juice,  two  ounces.  Mix. 
An  agreeable  demulcent. 

Flaxseed  Tea. — One  half  cupful  of  flaxseed  to  one  quart  of 
boiling  water;  boil  thirty  minutes  and  let  stand  a  little  while  near 
the  fire  to  thicken  more.     Strain,  and  add  lemon  juice  and  sugar. 

Currant  Jelly  {Fagge). — Red  or  black  currant  jelly,  dissolved 
in  hot  or  cold  water  or  strained  tamarind  tea,  make  excellent  invalid 
beverages. 

2.  Diuretic  and  Refrigerant. 

Lemonade  {Pavy). — Pare  the  rind  from  a  lemon  thinly,  and  cut 
the  lemon  into  slices.  Put  the  peel  and  sliced  lemon  into  a  pitcher 
with  one  ounce  of  white  sugar,  and  pour  over  them  one  pint  of 
boiling  water.  Cover  the  pitcher  closely,  and  digest  until  cold. 
Strain  or  pour  off  the  liquid. 

Citron  may  be  used  instead  of  lemon,  and  it  likewise  furnishes  a 
grateful  and  refrigerant  beverage. 

Lemonade,  Effervescing  {Ringer). — To  the  expressed  juice  of 
a  large  lemon  add  a  lump  or  two  of  sugar  previously  lightly  rubbed 
on  the  rind.  Pour  on  it  half  a  pint  of  cold  or  iced  water.  To  cause 
it  to  effervesce  put  it  into  a  large  tumbler  and  add  half  a  teaspoon- 
ful  of  bicarbonate  of  soda  or  potash.  Stir  and  drink  while  effervesc- 
ing.    A  very  agreeable  and  refreshing  beverage. 

Lemonade  {Ringer). — Pare  the  rind  of  three  lemons  as  thin  as 
possible,  add  one  quart  of  boiling  water  and  a  quarter  of  an  ounce 
of  isinglass.  Let  them  stand  till  next  day  covered  ;  then  squeeze  the 
juice  of  eight  lemons  upon  half  a  pound  of  lump  sugar;  when  the 
sugar  is  dissolved,  pour  the  lemon  and  water  upon  them,  mix  all  well 
together,  strain,  and  it  is  ready  for  use. 

Cream  -  of-  tartar  Drink.  —  Potus  Imperialis.  —  Imperial 
Drink  {Pavy). — Dissolve  a  drachm  or  a  drachm  and  a  half  of  cream 
of  tartar  in  a  pint  of  boiling  water,  and  flavour  with  lemon  peel  and 
sugar.  When  cold,  strain  and  take  ad  libitum  as  a  refrigerant  drink 
and  diuretic. 

Cream-of-tartar  Whey  {Pazy). — Stir  a  quarter  of  an  ounce 
of  cream  of  tartar  (a  large  teaspoonful  piled  up)  into  a  pint  of  boil- 
ing milk,  and  strain.  A  refrigerant  and  diuretic  drink,  which  is 
rendered  more  agreeable  by  the  addition  of  sugar. 

White  Wine  Whey  or  Posset  {Pavy). — To  half  a  pint  of 
milk  while  boiling  in  a  saucepan  add  one  wineglassful  of  sherry,  and 
afterwards  strain  through  a  muslin  cloth.  Sweeten  with  pounded 
sugar  according  to  taste.     A  useful  diuretic  drink  in  colds  and  mild 


FLUID   BEEF   PREPARATIONS.  760 

febrile  disorders.  For  a  child,  give  a  tablespoonful  every  two  or 
three  hours. 

Wine  Whey. — Milk,  one  pint;  wine  of  pepsin,  one  teaspoon- 
ful.  Heat  gently  to  115°  or  120°  F.,  let  stand,  break  the  curd, 
strain,  and  add  sherry  in  the  proportion  of  i  to  4  or  6.     Drink  cold. 

Tamarind  Whey  {Pavy). — Stir  two  tablespoonfuls  of  tamarinds 
into  a  pint  of  milk  while  boiling,  and  afterwards  strain.  This  forms 
a  refrigerant  and  slightly  laxative  drink. 

Mulled  Wine  {Ringer).— BoW  some  spice,  cloves,  nutmeg,  cin- 
namon, or  mace  in  a  little  water  just  to  flavour  the  wine;  then  add  a 
wineglassful  of  sherry  or  any  other  wine  and  some  sugar  ;  bring  it  to 
the  boiling  point,  and  serve  with  sippets  of  toast.  If  claret  is  used, 
it  will  require  more  sugar.  The  vessel  for  boiling  the  wine  should 
be  scrupulously  clean. 

FLUID   BEEF   PREPARATIONS. 

Beef  Juice  {Bartholoiv). — Broil  quickly  some  pieces  of  round  or 
sirloin  of  a  size  to  fit  in  the  cavity  of  a  lemon  squeezer  previously 
heated  by  being  dipped  in  hot  water.  The  juice,  as  it  flows  away, 
should  be  received  into  a  hot  wineglass,  and,  after  being  seasoned  to 
the  taste  with  salt  and  a  little  Cayenne  pepper,  taken  while  hot. 

Beef  Essence  {Yeo). — Cut  the  lean  of  beef  into  small  pieces  and 
place  them  in  a  wide-mouthed  bottle  securely  corked,  and  then  al- 
low it  to  stand  for  several  hours  in  a  vessel  of  boiling  water.  This 
may  be  given  to  infants,  who  can  not  take  milk,  in  teaspoonful  doses/ 
and  in  larger  quantities  to  adults. 

Beef  Tea  {Germain  SSe). — Meat  cut  into  small  pieces,  cold  water 
added,  and  then  gradually  heated  to  140°  or  160°  F.  Press,  strain, 
and  flavour  with  salt  and  pepper.  This  is  much  inferior  to  the 
preparations  made  with  hydrochloric  acid. 

Beef  Tea  {Pavy). — Put  a  pound  of  finely  minced  beef  into  a 
suitable  vessel  with  a  pint  of  cold  water.  Let  it  stand  for  an  hour, 
stirring  occasionally.  Place  the  vessel  containing  the  beef  into  a 
saucepan  of  water,  place  over  the  fire,  and  allow  the  water  to  boil 
gently  for  an  hour  (or  the  vessel  containing  the  beef  tea  may  be  put 
into  an  ordinary  oven  for  an  hour).  Pass  the  beef  tea  through  a 
strainer.  It  contains  a  quantity  of  fine  sediment,  which  should  be 
drunk  with  the  liquid.  Flavour  with  salt.  In  this  process  the  beef 
extract  should  not  be  exposed  to  a  temperature  of  more  than  170°  F. 

Beef  Tea  {Bryce). — Lean  beef,  chopped  fine,  free  from  fibre,  one 
pound  ;  water,  one  pint ;  sodium  bicarbonate,  ten  grains  ;  simmer 
half  an  hour  in  a  glass-covered  preserve  jar,  decant  the  fluid,  squeeze 
the  meat  to  a  pulp  in  a  lemon  squeezer,  return  both  to  jar,  add  ex- 
tract of  pancreas,  cover,  keep  at  140°  F.  for  twelve  hours,  shaking 


770 


APPENDIX. 


occasionally.  When  an  acid  taste  appears,  boil  two  or  three  minutes 
to  stop  further  fermentation. 

This  tea,  it  is  claimed,  equals  the  same  bulk  of  peptonised  milk 
in  nutrient  value. 

Chrystie's  Beef  Tea. — Macerate  for  one  hour  one  pound  of 
finely  minced  lean  beef  in  a  pint  of  water,  containing  fifteen  grains 
of  sodium  chloride  and  five  drops  of  dilute  hydrochloric  acid,  at 
1 00°  F. 

Filter  through  cheese  cloth,  and  wash  the  residue  with  half  a  pint 
of  fresh  water.  The  filtrate  is  transparent,  has  a  not  unpleasant 
taste,  and  contains  a  considerable  amount  of  albuminoids.  A  child 
of  two  years  may  take  two  or  three  ounces  daily. 

Beef  Tea  {Bartholow). — Chop  fine  a  pound  of  lean  beef  free 
from  fat,  tendons,  etc.,  and  digest  with  a  pint  of  cold  water  for  two 
hours.  Let  it  simmer  on  the  stove  for  three  hours,  at  a  temperature 
never  over  160°  F.  Make  up  the  water  lost  in  evaporation  by  add- 
ing cold  water,  so  that  a  pint  of  beef  tea  shall  represent  a  pound  of 
beef.     Strain,  and  carefully  express  all  fluid  from  the  beef. 

Beef  Tea  {U.  S.  Army  Hospital  Receipt  for  Twelve  Men). — Beef, 
twelve  pounds  ;  salt,  one  ounce. 

Directions. — The  beef  should  be  lean  and  juicy,  and  cut  into  small 
pieces.  Put  it  into  one  gallon  and  a  half  of  cold  water  with  the 
salt.  Let  it  boil  gently  three  hours.  If  it  should  boil  away  too 
fast,  add  the  requisite  quantity  of  boiling  water  and  let  it  boil  fifteen 
minutes  longer.  When  done  it  should  measure  twelve  pints.  Set  it 
aside  to  cool.  Remove  every  particle  of  grease,  and  heat  when  re- 
quired. In  case  of  a  deficiency  of  fresh  beef,  use  the  beef  extract 
supplied  in  the  hospital  stores. 

Beef  Extract  {U.  S.  Army  Hospital  Receipt  for  Twelve  Men). 

Directions. — Infuse  a  third  of  a  pound  of  fresh  beef,  finely  minced, 
in  fourteen  ounces  of  cold  soft  water,  to  which  a  few  drops  (four  or 
five)  of  muriatic  acid  and  a  little  salt  (from  ten  to  eighteen  grains) 
have  been  added.  After  digesting  for  an  hour  to  an  hour  and  a 
quarter,  strain  it  through  a  sieve  and  wash  the  residue  with  five 
ounces  of  cold  water,  pressing  it  to  remove  all  soluble  matter.  The 
mixed  liquid  will  contain  the  whole  of  the  soluble  constituents  of  the 
meat  (albumen,  creatine,  etc.),  and  it  may  be  drank  cold  or  slightly 
warmed.  The  temperature  should  not  be  raised  above  100°  F.,  as  at 
the  temperature  of  113°  F.  a  considerable  portion  of  the  albumen,  a 
very  important  constituent,  will  be  coagulated.  (Circular  Orders, 
No.  6,  1873.) 

Meat  Extract  {Rosenthal  and  Leube). — One  thousand  grammes 
of  lean  meat,  minced  fine,  are  placed  in  a  porcelain  vessel  with  one 
thousand  grammes  of  water,  and  twenty  centigrammes  of  dilute 
hydrochloric  acid.     This  is  placed  in  a  closed  Papin's  digester  and 


BROTHS   AND   SOUPS.  77  j 

boiled  for  ten  to  fifteen  hours.  The  mass  is  then  taken  out  and 
rubbed  in  a  mortar  to  a  paste.  It  is  again  boiled  in  the  closed 
digester  for  another  sixteen  to  twenty  hours;  after  this  it  is  neutral- 
ised with  pure  sodium  carbonate,  and  evaporated  to  a  sirupy  con- 
sistence. 

Restorative  Beef  Essence  (J^wger).— Take  one  ounce  of  fresh 
beef,  free  from  fat,  chop  fine,  and  pour  over  it  eight  ounces  of  soft 
water,  add  five  or  six  drops  of  dilute  hydrochloric  acid,  and  fifty  or 
sixty  grains  of  common  salt,  stir  it  well,  and  leave  for  three  hours  in 
a  cool  place.  Then  pass  the  fluid  through  a  hair  sieve,  pressing  the 
meat  slightly,  and  adding  gradually  toward  the  end  of  the  straining 
about  two  more  ounces  of  water.  The  liquid  thus  obtained  is  of  a 
red  colour,  possessing  the  taste  of  soup.  It  should  be  taken  cold,  a 
teaspoonful  at  a  time.  If  preferred  warm,  it  must  not  be  put  on  the 
fire,  but  heated  in  a  covered  vessel  placed  in  hot  water, 

BROTHS  AND   SOUPS. 

Chicken  Broth  {Bartholow). — Skin  and  chop  up  small  a  small 
chicken  or  half  a  large  fowl,  and  boil  it,  bones  and  all,  with  a  blade 
of  mace,  a  sprig  of  parsley,  and  a  crust  of  bread,  in  a  quart  of  water 
for  an  hour,  skimming  it  from  time  to  time.  Strain  through  a  coarse 
colander. 

Chicken,  Veal,  or  Mutton  Broth  {Yeo). — Chicken,  veal,  or 
mutton  broth  may  be  made  like  beef  tea,  substituting  chicken,  veal, 
or  mutton  for  beef,  boiling  in  a  saucepan  for  two  hours,  and  strain- 
ing. For  chicken  broth  the  bones  should  be  crushed  and  added. 
For  veal  broth  the  fleshy  part  of  the  knuckle  should  be  used.  Either 
may  be  thickened  and  their  nutritive  value  increased  by  the  addition 
of  pearl  barley,  rice,  vermicelli,  or  semolina. 

Mutton  and  Chicken  Broths  {Osier). — Mince  a  pound  of  either 
chicken  or  mutton,  freed  from  fat,  put  into  a  pint  of  cold  water,  and 
let  stand  in  a  cold  jar  on  ice  two  to  three  hours.  Then  cook  three 
hours  over  a  slow  fire,  strain,  cool,  skim  off  fat,  add  salt,  and  serve 
hot  or  cold.  Such  broth  is  much  better  than  any  manufactured  meat 
preparations.  Good  mutton  broth  is  difficult  to  make  on  account  of 
the  meat  containing  so  much  fat. 

Chicken  Broth(6^.  S.  Army  Hospital  Receipt  for  Twelve  Men).— 
Chicken,  one  ;  salt,  two  ounces;  flour,  two  ounces. 

Directions. — Cut  the  chicken  into  pieces.  Put  it  with  the  salt  into 
the  kettle  with  twelve  pints  of  cold  water.  Let  it  simmer  gently 
two  or  three  hours,  carefully  and  frequently  skimming  off  the 
grease.  Make  a  paste  of  the  flour  with  some  cold  water ;  stir  it 
in  and  boil  ten  minutes  longer.  It  should  measure  ten  pints  when 
done. 


772 


APPENDIX. 


Mutton  Broth(f^.  -S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Mutton,  six  pounds  ;  salt,  two  ounces  ;  rice,  two  ounces. 

Directions. — Break  the  bones  without  separating  the  meat.  Put  it 
into  twelve  pints  of  cold  water,  with  the  salt  and  rice  or  barley.  Boil 
gently  two  hours  and  a  half,  carefully  removing  all  the  scum  and  fat. 
If  the  broth  should  boil  away  too  much,  add  the  requisite  quantity 
of  boiling  water  to  make  twelve  pints,  and  let  it  boil  fifteen  minutes 
longer. 

Invalid  Broths. — To  one  pound  of  chopped  lean  meat,  either 
chicken,  mutton,  or  beef,  add  one  pint  of  cold  water  (or  one  pint  and 
a  half  on  ice  for  a  young  infant),  let  stand  in  a  covered  glass  fruit 
jar  for  four  to  six  hours,  cook  for  three  hours  in  a  closed  jar  over  a 
slow  fire,  strain,  cool,  skim  off  the  fat,  clear  with  egg,  season,  and 
feed  warm  or  cold. 

Bouillon  (Broth)  as  used  in  the  Hospitals  of  Paris  {Yeo). — 
Raw  meat,  without  bone,  one  kilogramme  ;  fresh  vegetables,  four 
hundred  grammes  (about  one  pound) ;  salt,  ten  grammes  (about 
one  hundred  and  fifty  grains).  Boil  very  slowly  over  a  gentle 
fire. 

Nourishing  Soup  {Ringer). — Stew  two  ounces  of  the  best  well- 
washed  sago  in  a  pint  of  water  till  it  is  quite  tender  and  very  thick  ; 
then  mix  it  with  half  a  pint  of  good  boiling  cream  and  the  yolks  of 
two  fresh  eggs.  Blend  the  whole  carefully  with  one  quart  of  essence 
of  beef.  The  beef  essence  must  be  heated  separately,  and  mixed 
while  both  mixtures  are  hot.  A  little  of  this  may  be  warmed  at  a 
time. 

Consomme. — Consomme'  may  be  flavoured  with  vegetable  ex- 
tracts or  expressed  juice  of  vegetables  boiled  in  it.  Thicken  soups 
with  arrowroot,  ground  rice,  or  cornflower. 

Beef  Tea  with  Oatmeal  {Anderson). — This  forms  a  very  nutri- 
tious food.  Take  two  tablespoonfuls  of  oatmeal  and  two  of  cold 
water  and  mix  them  thoroughly ;  then  add  a  pint  of  good  beef  tea 
which  has  just  been  brought  to  the  boiling  point.  Boil  together  for 
five  minutes,  stirring  it  well  all  the  time,  and  strain  through  a  hair 
sieve. 

SOLID    MEAT    PREPARATIONS. 

Raw-meat  Diet  J^Ringer). — From  two  ounces  of  rump  steak 
take  away  all  fat,  cut  into  small  squares  without  entirely  separating 
the  meat,  place  in  a  mortar,  and  pound  for  five  or  ten  minutes;  then 
add  three  or  four  tablespoonfuls  of  water  and  pound  again  for  a 
short  time,  afterwards  removing  all  sinew  or  fibre ;  add  salt  to  taste. 
Before  using,  place  the  cup  or  jar  containing  the  pounded  meat  in 
hot  water  until  just  warm. 

Or   scrape   the   beefsteak  with  a  sharp  knife  and,  after  removing 


MILK   PREPARATIONS.  7-3 

all  fat  and  tendon,  if  not  already  in  a  complete  pulp,  pound  in  a 
mortar.  Flavour  with  salt  and  pepper.  This  may  be  taken  in  the 
form  of  a  sandwich  between  thin  bread  and  butter  or  mixed  with 
water  to  the  consistence  of  cream.  If  preferred,  the  meat  may  be 
rolled  into  balls  with  a  little  white  of  egg  and  broiled  for  two 
minutes,  or  until  the  outside  turns  grey — just  long  enough  to  re- 
move the  raw  taste. 

This  diet  is  excellent  for  children  with  diarrhoea,  also  for  adults 
who  suffer  from  irritable  bowels  or  chronic  diarrhoea. 

Meat  Biscuits  (Parses).— Mix  together,  cook,  and  bake  one 
pound  of  flour,  one  pound  of  meat,  one  quarter  of  a  pound  of  suet,  one 
half  pound  potatoes  with  a  little  sugar,  onion,  salt,  pepper,  and  spices. 
A  palatable  meat  biscuit,  weighing  about  one  pound  and  a  quarter, 
containing  10  to  12  per  cent  of  water,  is  thus  obtained  which  keeps 
quite  unchanged  for  four  months. 

Raw-meat  Sandwiches  (/rom  Food).— Three  ounces  of  raw 
beef  or  mutton,  one  ounce  of  very  fine  bread  crumbs,  one  teaspoon- 
ful  of  sugar  ;  cut  the  meat  very  fine,  rub  it  through  a  hair  sieve,  then 
pound  it  in  a  mortar  into  a  paste.  Mix  with  it  the  bread  crumbs, 
sugar,  a  little  salt  and  pepper;  spread  it  between  thin  slices  of  either 
brown  or  white  bread  and  butter. 

Chicken  Jelly  {Adams). — Clean  a  fowl  that  is  about  a  year  old, 
remove  skin  and  fat;  chop  fine,  bones  and  flesh  place  in  pan  with 
two  quarts  of  water;  heat  slowly;  skim  thoroughly;  simmer  five  to 
six  hours ;  add  salt,  mace,  or  parsley  to  taste,  strain ;  cool.  When 
cool,  skim  off  the  fat. 

The  jelly  is  usually  relished  cold,  but  may  be  heated.  Give  often 
in  small  quantities. 

Enema  of  Meat  and  Pancreas  {Leube). — Mince  from  one 
hundred  and  fifty  to  three  hundred  grammes  of  meat,  and  mix  with 
fifty  to  one  hundred  grammes  of  finely  chopped  pancreas,  free  from 
fat.  Beat  the  mixture  into  a  paste  with  a  pestle  or  spoon,  adding  a 
little  lukewarm  water  to  make  it  of  a  suitable  consistence  for  injec- 
tion through  the  enema  tube.  Use  warm  ;  if  cold  it  may  excite  the 
rectum  and  cause  expulsion.  If  thought  desirable,  from  twenty-five 
to  fifty  grammes  of  fat  may  be  mixed  intimately  with  the  mass  by 
the  help  of  a  warm  pestle.  A  syringe  with  a  wide  nozzle  must  be 
used. 

MILK    PREPARATIONS. 

Milk-and-cinnamon  Drink  {Ringer). — Boil  in  one  pint  of  new 
milk  sufficient  cinnamon  to  flavour, it  pleasantly,  and  sweeten  with 
white  sugar.  This  may  be  taken  cold  with  a  teaspoonful  of  brandy, 
and  is  very  good  in  cases  of  diarrhoea.  Children  may  take  it  warm 
without  brandy. 


774 


APPENDIX. 


Milk  Punch. — Make  by  adding  brandy  or  whisky  or  rum  to 
milk  in  the  proportion  of  about  one  to  four  or  six  parts  of  milk  ; 
flavour  with  sugar  and  nutmeg;  shake  well. 

Sherry  or  Brandy  and  Milk  {Ringer). — To  one  tablespoon- 
ful  of  brandy  or  one  wineglassful  of  sherry,  in  a  bowl  or  cup,  add 
powdered  sugar  and  a  very  little  nutmeg  to  taste.  Warm  a  break- 
fast cupful  of  new  milk  and  pour  into  a  pitcher.  Pour  the  contents 
from  a  height  over  the  wine,  sugar,  etc.      The  milk  must  not  boil. 

Rum  and  Milk  {Fothergill). — Half  a  pint  of  new  milk,  one  egg, 
one  to  two  teaspoonfuls  of  powdered  sugar,  grated  nutmeg,  one  to 
two  teaspoonfuls  of  good  old  Jamaica  rum.     Mix. 

Junket  {Anderson). — Sweeten  with  white  sugar  one  pint  of  good 
milk.  If  wine  is  allowed,  a  dessertspoonful  of  sherry  is  an  improve- 
ment. Heat  to  new  milk  warmth,  pour  into  a  shallow  dish,  and  stir 
in  two  teaspoonfuls  of  essence  of  rennet.  This  will  form  a  slight 
curd.  Grate  a  little  nutmeg  over  it  or  add  a  pinch  of  powdered  cin- 
namon. Serve  when  quite  cold.  In  cold  weather  the  milk  should  be 
placed  in  a  warm  room  to  set.  An  excellent  food,  and  good  substi- 
tute for  milk  in  typhoid  fever,  etc. 

Artificial  Human  Milk  {Frankland). — Allow  one  third  of  a 
pint  of  new  milk  to  stand  twelve  hours,  remove  the  cream,  and  mix 
it  with  two  thirds  of  a  pint  of  perfectly  fresh  cow's  milk.  Take  the 
milk  from  which  the  cream  was  removed  and  put  a  piece  of  rennet 
about  an  inch  square  (fluid  rennet  may  be  employed)  into  it.  Keep 
the  vessel  containing  it  in  a  warm  place  until  the  milk  is  fully 
curdled,  an  operation  requiring  five  to  fifteen  minutes,  according 
to  the  activity  of  the  rennet,  which  should  be  removed  as  soon  as 
the  curdling  commences,  and  put  into  an  eggcup  for  use  on  subse- 
quent occasions,  as  it  may  be  employed  daily  for  a  month  or  two. 
Break  up  the  curd  repeatedly,  and  carefully  separate  the  whole  of 
the  whey,  which  should  then  be  rapidly  heated  to  boiling  in  a  small 
tin  pan,  placed  over  a  spirit  or  gas  lamp.  During  the  heating  a 
further  quantity  of  casein  [albumin  ?],  technically  called  "fleetings," 
separates,  and  must  be  removed  by  straining  through  clean  muslin. 
Now  dissolve  one  hundred  and  ten  grains  of  powdered  sugar  of  milk 
in  the  hot  whey,  and  mix  it  with  two  thirds  of  a  pint  of  new  milk  to 
which  the  cream  from  the  other  fluid  has  already  been  added,  as  al- 
ready described.  The  artificial  milk  should  be  used  within  twelve 
hours  of  its  preparation. 

Biedert's  Cream  Mixture. — Mix  four  ounces  of  cream  with 
twelve  ounces  of  warm  water  and  add  one  half  ounce  of  milk  sugar. 

Koumiss  {Anderson). — To  one  pint  of  new  milk  add  three  ounces 
of  water,  three  ounces  of  old  koumiss  (for  a  ferment),  and  one  ounce 
of  saturated  solution  of  sugar  of  milk.  Put  all  in  a  large  jug,  cover 
carefully,  and  set  the  jug  in   a  warm  place  for  twenty-four  hours. 


EGG   PREPARATIONS.  --. 

By  that  time  a  thick  crust  will  have  formed  on  the  surface  of  the 
mixture;  beat  this  up  thoroughly  and  mix  all  well.  Then  put  the 
whole  into  champagne  bottles,  which  should  be  no  more  than  two 
thirds  full,  and  cork  and  wire.  Shake  the  bottles  daily.  The  kou- 
miss will  be  fit  for  use  in  two  days,  but  it  is  much  improved  by  keep- 
ing for  about  six  weeks.     It  should  be  drawn  off  with  a  tap. 

Home-made  Koumiss.— Boil  fresh  milk,  and  when  nearly  cold 
put  into  quart  bottles,  leaving  room  to  shake.  Add  half  an  ounce  of 
crushed  lump  sugar  and  a  piece  of  Vienna  yeast  the  size  of  a  hazel  nut 
(i.  e.,  twenty  grains),  cork  with  new  corks,  tie  down,  keep  cool,  lay 
the  bottles  horizontal,  but  shake  twice  daily.  Ready  to  drink  on 
sixth  day,  or  earlier  in  hot,  later  in  cold  weather. 

The  koumiss  can  be  made  thinner  by  using  skimmed  milk. 

Home-made  Lime  Water. — Pour  two  quarts  of  hot  water 
over  fresh,  unslacked  lime  (size  of  a  walnut),  stir  till  slacked,  let 
stand  till  clear  and  bottle.  Often  ordered  with  milk  to  neutralise 
acidity  of  the  stomach. 


EGG   PREPARATIONS. 

Eggnog.— Eggnog  is  made  by  adding  the  beaten  yolk  of  egg  and 
a  little  spirits  to  a  tumblerful  of  milk,  stirring  well,  adding  sugar  and 
the  white  of  the  egg,  separately  beaten.  The  digestibility  of  both  of 
these  highly  nourishing  and  stimulating  preparations  is  enhanced  by 
the  addition  of  half  an  ounce  of  lime  water,  which  does  not  affect 
the  taste. 

Egg  and  Wine  {Ringer). — Take  one  egg,  half  a  glass  of  cold 
water,  one  glass  of  sherry,  sugar,  and  a  very  little  nutmeg  grated. 

Beat  the  egg  to  a  froth  with  a  tablespoonf ul  of  cold  water.  Make 
the  wine  and  water  hot,  but  not  boiling;  pour  on  the  egg,  stirring 
all  the  time.  Add  sufficient  sugar  to  sweeten,  and  a  very  little  nut- 
meg. Put  all  into  a  porcelain-lined  saucepan  over  a  gentle  fire  and 
stir  one  way  till  it  thickens,  but  do  not  let  it  boil.  Serve  in  a  glass 
with  crisp  biscuits  or  sippets  of  toast. 

Eggnog  {Bart/iolotn). — Scald  some  new  milk  by  putting  it,  con- 
tained in  a  jug,  into  a  saucepan  of  boiling  water,  but  it  must  not  be 
allowed  to  boil.  When  quite  cold  beat  up  an  egg  with  a  fork  in  a 
tumbler  with  some  sugar;  beat  quite  to  a  froth  ;  add  a  dessertspoon- 
ful of  brandy  and  fill  up  the  tumbler  with  scalded  milk.  A  nutritive 
drink  in  acute  disease. 

Brandy  and  Egg  Mixture  {British  Pharmacopoeia). — Rub  to- 
gether the  yolks  of  two  eggs  and  half  an  ounce  of  refined  sugar,  and 
add  four  ounces  of  Cognac  and  four  ounces  of  cinnamon  water.  A 
more  generally  useful  mixture  may  be  made  with  half  this  quantity 
of  brandy. 


776 


APPENDIX. 


Stokes's  Cognac  Mixture. — Best  Cognac,  distilled  water,  each 
fifteen  ounces;  yolk  of  one  egg;  sirup,  six  ounces.  Mix.  Give  a 
tablespoonful  every  two  or  three  hours. 

Egg  and  Brandy  Mixture  {Anderson). — Beat  up  three  eggs  to 
a  froth  in  four  ounces  of  cold  water  and  then  add  four  ounces  of 
brandy.  Mix  well  and  sweeten  to  taste.  A  little  nutmeg  may  be 
added.     Give  a  tablespoonful  or  so  at  a  time. 

Lemonade  with  Eggs  {Ringer). — The  juice  of  four  lemons,  the 
rinds  of  two,  half  a  pint  of  sherry,  four  eggs,  six  ounces  of  loaf  sugar, 
one  pint  and  a  half  of  boiling  water. 

Pare  the  lemon  rind  thinly,  put  it  into  a  pitcher  with  the  sugar, 
and  pour  the  boiling  water  on  it.  Let  it  cool,  then  strain,  and  add 
the  wine,  lemon  juice,  and  eggs,  previously  well  beaten  and  strained. 
Mix  all  together  and  it  is  ready  for  use. 

Savoury  Custard  {Anderson). — Add  the  yolks  of  two  eggs  to  a 
cupful  of  beef  tea,  with  pepper  and  salt  to  taste.  Butter  a  cup  or 
jam  pot,  pour  the  mixture  into  it,  and  let  it  stand  in  a  pan  of  boiling 
water  till  the  custard  is  set. 

Milk  for  Puddings  or  Stewed  Fruit  {Ringer). — Boil  a  strip  of 
lemon  and  two  cloves  in  a  pint  of  milk;  mix  half  a  teaspoonful  of 
arrowroot  in  a  little  cold  milk  and  add  it  to  the  boiling  milk  ;  stir  it 
until  about  the  consistency  of  cream.  Have  ready  the  yolks  of  three 
eggs  beaten  up  well  in  a  little  milk.  Take  the  hot  milk  off  the  fire 
and  as  it  cools  add  the  eggs  and  a  tablespoonful  of  orange-flower 
water,  stirring  it  constantly  till  quite  cool.  Keep  it  in  a  very  cool 
place  till  required  for  use. 

Rice  Soup  {Ringer). — Take  three  ounces  of  rice,  the  yolks  of 
two  eggs,  half  a  pint  of  cream  or  new  milk,  one  quart  of  stock. 

Boil  the  rice  in  the  stock  and  rub  half  of  it  through  a  tammy, 
put  the  stock  in  a  stewpan,  add  the  rest  of  the  rice  whole,  and  sim- 
mer gently  for  five  minutes.  Have  ready  the  milk  or  cream,  boiled. 
Beat  the  yolks  of  the  eggs  and  mix  them  gradually  with  the  cream. 
Take  the  soup  off  the  fire,  add  the  cream  and  egg,  stirring  them  well 
together  as  you  mix  them.  Heat  gradually,  but  do  twt  boil,  or  the 
eggs  will  curdle. 

A  Gruel  {Ringer). — Beat  an  egg  to  a  froth,  add  a  wineglass  of 
sherry,  flavour  with  a  lump  of  sugar,  a  strip  of  lemon  peel,  and  a  little 
grated  nutmeg.  Have  ready  some  gruel,  very  smooth  and  hot,  stir 
in  the  wine  and  egg,  and  serve  with  crisp  toast.  Arrowroot  may  be 
made  in  the  same  way. 

Caudle  {Yeo). — Beat  up  an  ^gg  to  a  froth  ;  add  a  glass  of  sherry 
and  half  a  pint  of  gruel.  Flavour  with  a  lemon  peel,  nutmeg,  and 
sugar. 


FARINACEOUS   FOODS.  7^7 

FARINACEOUS   FOODS. 

Arrowroot  Blancmange  { J? inger).— Take  two  tablespoonfuls 
of  arrowroot,  three  quarters  of  a  pint  of  milk,  lemon,  and  sugar  to 
taste. 

Mix  the  arrowroot  with  a  little  milk  to  a  smooth  batter ;  put  the 
rest  of  the  milk  on  the  fire  and  let  it  boil,  sweeten,  and  flavour  it, 
stirring  all  the  time,  till  it  thickens  sufficiently.  Put  into  a  mould 
till  quite  cold. 

Arrowroot  (Paty).— Mix  thoroughly  two  teaspoonfuls  of  arrow- 
root with  three  tablespoonfuls  of  cold  water,  and  pour  on  them  half 
a  pint  of  boiling  water,  stirring  well  meanwhile.  If  the  water  is  quite 
boiling,  the  arrowroot  thickens  as  it  is  poured  on,  and  nothing  more 
is  necessary.  If  only  warm  water  is  used,  the  arrowroot  must  be 
afterwards  boiled  until  it  thickens.  Sweeten  with  loaf  sugar  and 
flavour  with  lemon  peel  or  nutmeg,  or  add  sherry,  port  wine,  or 
brandy,  if  required.  Boiling  milk  may  be  employed  instead  of  water, 
but  when  this  is  done  no  wine  must  be  added,  as  it  would  otherwise 
curdle. 

Oatmeal  Gruel  (plain)  (from  Food).— Two  tablespoonfuls  of 
oatmeal,  one  saltspoonful  of  salt,  one  scant  teaspoonful  of  sugar, 
one  cupful  of  boiling  water,  one  cupful  of  milk.  Mix  the  oatmeal, 
salt,  and  sugar  together,  and  pour  on  the  boiling  water.  Cook  for 
thirty  minutes ;  then  strain  through  a  fine  wire  strainer  to  remove 
the  hulls,  place  again  on  the  stove,  add  the  milk,  and  heat  just  to  the 
boiling  point.     Serve  hot. 

Scotch  Beef  Broth. — To  a  pint  of  beef  broth  which  has  been 
carefully  strained  and  seasoned  and  from  which  all  the  fat  has  been 
removed,  add  a  teaspoonful  of  oatmeal  and  boil  gently  for  two  hours. 
Strain  and  serve  hot. 

In  this  preparation  the  oatmeal  should  be  soft  and  jellylike,  and 
if  too  much  water  evaporates  during  the  boiling,  more  should  be 
added. 

Corn  Starch  {C/.  S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Corn  starch,  six  ounces;  milk,  three  pints;  water,  twelve  ounces. 

Directions. — Mix  the  corn  starch  into  a  smooth  paste  with  cold 
water.  The  milk  and  water  must  be  boiling,  to  which  add  a  little 
salt.     Stir  in  the  corn  starch.     Let  it  boil  three  or  five  minutes. 

Farina  Pudding  {U.  S.  Army  Hospital  Receipt  /or  Twelve  Men). — 
Farina,  half  a  pound;  milk,  two  pints;  water,  one  pint;  sugar,  two 
and  a  half  ounces;  eggs,  four  ounces;  nutmeg,  half  an  ounce. 

Directions. — Put  the  water  into  a  stewpan  with  a  little  salt.  When 
it  boils,  stir  in  the  farina.  Let  it  boil  twenty  minutes.  Stir  in  the 
milk,  which  must  be  hot.  Beat  the  eggs  until  they  are  very  light; 
mix  the  sugar  with  them.     Stir  in  the  eggs  and  sugar  with  the  farina. 


778- 


APPENDIX. 


Add  the  spice.     Put  it  into  a  moderate  oven  and  bake  a  half  or  three- 
quarters  of  an  hour. 

Boiled  Rice  {U.  S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Rice,  twelve  ounces;  salt,  half  an  ounce;  water,  three  pints. 

Directiotis. — Put  the  salt  and  water  into  a  stewpan.  When  boiling, 
add  the  rice,  previously  thoroughly  washed.  Boil  for  ten  minutes, 
or  until  each  grain  becomes  soft.  Drain  it  on  a  colander.  Grease 
the  stewpan  with  clarified  drippings  or  lard.  Put  back  the  rice.  Let 
it  swell  slowly  near  the  fire,  or  in  a  slow  oven,  for  about  twenty 
minutes,  until  the  grains  are  well  separated. 

Rice  Gruel  {Chambers). — Ground  rice,  two  ounces;  powdered 
cinnamon,  quarter  of  an  ounce ;  water,  four  pints.  Boil  forty  min- 
utes and  add  a  teaspoonful  of  orange  marmalade. 

Rice  Milk  {Anderson). — Wash  two  tablespoonfuls  of  good  rice 
and  put  it  into  a  saucepan  with  a  quart  of  milk.  Let  it  simmer 
gently  till  the  rice  is  tender,  and  stir  from  time  to  time  to  prevent 
burning;  sweeten  to  taste.  If  desirable,  serve  with  stewed  apples 
or  prunes.  Sago,  tapioca,  etc.,  are  prepared  in  the  same  way.  If  an 
egg  is  to  be  added,  beat  the  white  and  yolk  separately,  and  add 
them  to  the  rice  after  it  has  been  taken  from  the  fire. 

Rice  and  Apple  {Ringer). — Boil  about  two  tablespoonfuls  of 
rice  in  a  pint  and  a  half  of  new  milk,  and  simmer,  stirring  it  from 
time  to  time  till  the  rice  is  quite  tender.  Have  ready  some  apples, 
peeled,  cored,  and  stewed  to  a  pulp,  and  sweetened  with  a  very  little 
loaf  sugar.  Put  the  rice  round  a  plate  and  the  apple  in  the  mid- 
dle, and  serve. 

Rice  Cream  {Ringer). — To  a  pint  of  new  milk  add  a  quarter  of 
a  pound  of  rice,  a  lump  of  butter  the  size  of  a  walnut,  a  little  lemon 
peel,  and  a  tablespoonful  of  powdered  sugar.  Boil  them  together 
for  five  minutes,  then  add  half  an  ounce  of  isinglass  which  has  been 
dissolved,  and  let  the  mixture  cool.  When  cool  add  half  a  pint  of 
good  cream  whisked  to  a  froth,  mix  together,  and  set  it  for  a  time 
in  a  very  cool  place,  or  on  ice;  when  used,  turn  it  out  of  the  basin 
into  a  dish,  and  pour  fruit  juice  around  it,  or  some  stewed  apple  or 
pear  may  be  served  with  it. 

Rice  Cream  {from  Food,  January.,  J^Sg4). — Two  tablespoonfuls 
of  rice.  Two  cups  of  milk.  One  saltspoonful  of  salt.  Two  table- 
spoonfuls of  sugar.     Two  eggs. 

Cleanse  the  rice  by  washing  it  several  times  in  cold  water;  cook 
it  in  a  double  boiler  with  the  milk  until  the  grains  will  mash.  Three 
hours  will  generally  be  required  to  do  this.  Should  the  milk  evap- 
orate, restore  the  amount  lost.  When  the  rice  is  perfectly  soft, 
press  it  through  a  coarse  soup  strainer  or  colander  into  a  saucepan, 
return  it  to  the  fire,  and  while  it  is  heating  beat  the  eggs,  sugar, 
and  salt  together  until   very  light.     When   the  rice  boils,  pour  the 


FARINACEOUS   FOODS. 


779 


eggs  in  rather  slowly,  stirring  lightly  with  a  spoon  for  three  or  four  , 
minutes,  or  until  it  coagulates,  and  the  whole  is  like  a  thick,  soft  pud- 
ding; then  remove  from  the  fire,  and  pour  it  into  a  dish.     By  omit- 
ting the  yolks  and  using  the  whites  of  the  eggs  only,  a  delicate  cream 
is  obtained. 

Malt  (Ground)  and  Rice  Pudding  (F^-^). — Stir  an  ounce  of 
ground  malt  into  a  pint  of  boiling  milk,  strain  through  a  sieve,  and 
add  the  milk  to  two  ounces  of  well-soaked  rice.  Mix  well,  and 
stand  for  ten  minutes  in  a  warm  place,  then  bake  for  an  hour. 

Cracker  Gruel  {from  Food,  January,  i8g4). — Two  tablespoons 
of  cracker  crumbs.  One  scant  saltspoon  of  salt.  One  scant  tea- 
spoon of  sugar.     One  cup  of  boiling  water.     One  cup  of  milk. 

To  make  the  cracker  crumbs,  roll  some  crackers  on  a  board  until 
they  are  fine.  Water  crackers  are  good,  cream  crackers  are  better ; 
mix  the  salt  and  sugar  with  the  crumbs,  pour  on  the  boiling  water, 
put  in  the  milk,  and  simmer  it  for  two  minutes.  The  gruel  does  not 
need  long  cooking,  for  the  cracker  crumbs  are  already  thoroughly 
cooked.     Do  not  strain. 

Indian-meal  Gruel  {from  Food,  January,  lSg4). — Two  tea- 
spoonfuls  of  corn  meal.  One  tablespoonful  of  flour.  One  teaspoon- 
ful  of  salt.  One  teaspoonful  of  sugar.  One  quart  of  boiling  water. 
One  cup  of  milk. 

Mix  the  corn  meal,  flour,  salt,  and  sugar  into  a  thin  paste  with 
cold  water,  and  pour  into  it  the  boiling  water.  Cook  it  in  a  double 
boiler  for  three  hours.  No  less  time  than  that  will  cook  the  corn 
meal  thoroughly.     Then  add  the  milk,  and  it  is  ready  to  serve. 

Bread  Jelly  {Chrystie). — Pour  boiling  water  on  stale  bread,  and 
let  it  soak  for  an  hour.  Pour  ofi:  the  water,  add  fresh  water,  and 
boil  down  until  a  thick  mass  is  obtained  which  becomes  jellylike 
on  cooling,  and  may  be  eaten  with  milk  or  cream  and  sugar. 

Milk  Porridge  ( U.  S.  Army  Hospital  Receipt  for  Twelve  Men).— 
Milk,  eight  pints;  flour,  twelve  ounces;  water,  three  pints. 

Directions.— i:\i^  flour  to  be  used  for  milk  porridge  should  be 
previously  prepared  by  being  tied  up  closely  in  a  bag  and  boiled 
four  or  five  hours.  It  can  then  be  grated  to  powder,  which  should 
be  mixed  into  a  smooth  paste  with  cold  water.  Add  to  the  milk 
the  prescribed  quantity  of  water,  and  stir  in  the  flour,  with  a  little 
salt.     Let  it  boil  ten  minutes,  stirring  all  the  time. 

Fothergill's  Amylaceous  Food.— Of  rice,  well  washed,  of 
arrowroot,  tapioca,  and  pearl  barley,  take  each  an  ounce,  add  two 
quarts  of  water,  and  boil  down  to  a  quart ;  then  flavour  with  can- 
died eringo. 

Barley  Jelly  {Eustace  Smith).— Yw\.  two  tablespoonfuls  of  washed 
pearl  barley  into  a  pint  and  a  half  of  water,  and  slowly  boil  down 
to  a  pint ;  strain,  and  let  the  liquid  settle  into  a  jelly.     Two  tea- 


78o 


APPENDIX. 


spoonfuls  of  this,  dissolved  in  eight  ounces  of  warmed  and  sweet- 
ened milk,  are  enough  for  a  single  feeding,  and  such  a  meal  may  be 
allowed  twice  a  day. 

Panada  {Ringer). — Take  the  crumb  of  a  penny  roll  and  soak 
it  in  milk  for  half  an  hour,  then  squeeze  the  milk  from  it;  have 
ready  an  equal  quantity  of  chicken  or  veal,  scraped  very  fine  with 
a  knife  ;  pound  the  bread  crumb  and  meat  together  in  a  mortar. 
It  may  be  cooked  either  mixed  with  veal  or  chicken  broth,  or 
poached  like  an  tgg.  By  taking  it  up  in  two  spoons,  in  pieces 
the  shape  of  an  e.gg,  after  seasoning,  it  may  be  served  with  mashed 
potato. 

Another  Caudle  {Ringer). — Mix  well  together  one  pint  of  cold 
gruel  with  a  wineglassful  each  of  good  cream  and  sherry  and  a 
tablespoonful  of  noyeau,  and  sweeten  with  sugar  candy. 

Almond  Cakes  for  Diabetics  {Seegen). — Take  of  blanched, 
sweet  almonds  a  quarter  of  a  pound,  beat  them  as  fine  as  possible  in 
a  stone  mortar;  remove  the  sugar  contained  in  this  meal  by  putting 
it  into  a  linen  bag  and  steeping  it  for  a  quarter  of  an  hour  in  boiling 
water  acidulated  with  vinegar  ;  mix  this  paste  thoroughly  with  three 
ounces  of  butter  and  two  eggs.  Next  add  the  yolks  of  three  eggs 
and  a  little  salt,  and  stir  well  for  some  time.  Whip  up  the  whites  of 
three  eggs  and  stir  in.  Put  the  dough  thus  obtained  into  greased 
moulds,  and  dry  by  a  slow  fire. 

Macaroni  Boiled  {U.  S.  Army  HospitcU  Receipt  for  Twelve  Men). 
— Macaroni,  one  pound  ;  salt,  a  quarter  of  an  ounce  ;  boiling  water, 
six  pints. 

Directions. — Wipe  the  macaroni  carefully.  Break  into  four-inch 
lengths.  Put  with  the  salt  into  cold  water  and  boil  until  tender,  but 
not  until  it  bursts  or  becomes  a  pulp.  Drain  off  the  water  at  once, 
and  season  with  butter.  The  liquor  from  the  broth  of  macaroni 
makes  a  good  broth. 

GELATIN    PREPARATIONS. 

Port  Wine  Jelly  {Ringer). — Put  into  a  jar  one  pint  of  port 
wine,  two  ounces  of  gum  arable,  two  ounces  of  isinglass,  two  ounces 
of  powdered  white  sugar  candy,  a  quarter  of  a  nutmeg  grated  fine, 
and  a  small  piece  of  cinnamon.  Let  this  stand  closely  covered  all 
night.  The  next  day  put  the  jar  into  boiling  water  and  let  it  simmer 
until  all  is  dissolved,  then  strain,  let  stand  till  cold,  and  then  cut  into 
small  pieces  for  use. 

Milk,  Rum,  and  Isinglass  {Ringer). — Dissolve  in  a  little  hot 
water  over  the  fire  a  pinch  of  the  best  isinglass;  let  it  cool,  and  mix 
a  dessertspoonful  of  rum  with  it  in  a  tumbler,  and  fill  up  the  glass 
with  new  milk. 


GELATIN   PREPARATIONS.  78  c 

Nutritious  Coffee  {Ringer). — Dissolve  a  little  isinglass  in  water, 
then  put  half  an  ounce  of  freshly  ground  coffee  into  a  saucepan  with 
one  pint  of  new  milk,  which  should  be  nearly  boiling  before  the 
coffee  is  added  ;  boil  both  together  for  three  minutes ;  clear  it  by 
pouring  some  of  it  into  a  cup  and  dashing  it  back  again,  add  the 
isinglass,  and  leave  it  to  settle  on  the  hob  for  a  few  minutes.  Beat 
up  an  egg  in  a  breakfast  cup,  and  pour  the  coffee  upon  it ;  if  pre- 
ferred, drink  it  without  the  egg. 


/ 


INDEX 


Abnormal  cravings,  304. 

Abscess  of  liver,  565. 

Absinthe,  232. 

Absorption   of  food,   334 ;    from   rectum, 

375. 
Absorptive  power  of  stomach,  495. 
Acid,  albumin,  325  ;  boric,  in  foods,  260 ; 

hydrochloric,  320 ;  lactic,  46  ;  salicylic, 

in  foods,  260,  358  ;«6alts  in  gastric  juice, 

493- 
Acidity  of  gastric  juice,  491. 
Acids,  fatty,  in  cod-liver  oil,  180 ;  in  fruits, 

157  i  organic,  in  apples,  162  ;  vegetable, 

41- 
Acidulous  waters,  191. 
Acne,  593. 

Adams's  dietary  for  young  children,  738. 
Addison's  disease,  671. 
Adult  life,  food  for,  285. 
Adulteration  of  food,  356  ;  of  liquors,  231  ; 

of  wines,  231. 
Aerated  bread,  124. 
Aged,  food  for  the,  285. 
Albumen,  90,  gi. 
Albumin,  45  ;  oxidation  of,  18  ;  vegetable, 

144. 
Albuminoids,  325  ;  estimation  of,  in  milk, 

51- 

Albuminuria,  functional,  466. 

Albumoses,  321,  325. 

Alcohol,  205  ;  absorption,  212 ;  action  on 
body  temperature,  210  ;  action  on  circu- 
lation, 209  ;  action  on  gastric  digestion, 
211  ;  action  on  mucous  membranes, 
211;  action  on  muscular  system.  210; 
action  on  nerves,  209 ;  antipyretic  ac- 
tion, 216  ;  as  a  cardiac  stimulant,  214  ; 
as  a  food,  2cx),  217  ;  as  a  stimulant,  209  ; 
as  a  tonic,  214  ;  as  a  vascular  stimulant, 
214 ;  climate  and,  213  ;  clinical  uses, 
214;  consumption  of,  219;  diuretic  ac- 
tion, 211  ;  dosage,  217 :  elimination,  213 ; 


force  value,  206 ;  for  nervous  diseases, 
215  ;  hypodermic  use,  212  ;  in  enemata, 
382  ;  in  fevers,  216,  393 ;  in  gout,  629 ; 
in  tuberculosis,  434 ;  in  typhoid  fever, 
403  ;  not  in  children's  diet,  734  ;  physio- 
logical action,  208  ;  poisoning,  213,  364  ; 
selection  of  proper  form  of,  218  ;  time 
for  giving,  217  ;  uses  of,  206. 

Alcoholism,  364  ;  treatment,  366. 

Ale,  220.  232  ;  brewing,  219. 

Alimentary  pastes,  134, 

Alkaline  purges,  188,  190. 

Allspice,  236. 

Almond  cakes,  656,  780 ;  oil,  Java,  179. 

Almonds,  171  ;  salted,  171. 

Alum  in  baking  powder,  123. 

Ammonia  in  baking  powder,  123. 

Amoeba,  31. 

Amylaceous  food,  Fothergill's,  779. 

Anaemia,  alcohol  in,  217  ;  bone  marrow  for, 
177  ;  dietetic  treatment,  460  ;  dyspepsia 
and,  501 ;  exercise  and  air  for,  459 ; 
pathological  physiology,  458 ;  perni- 
cious, 463. 

Anxsthetisation,  diet  after,  674  ;  food 
and,  675  ;  preparation  for,  674. 

Analysis,  approximate,  of  a  man,  2  ;  of 
liqueurs,  232. 

Aneurism,  456  ;  TufnelPs  diet  for,  457. 

Angina  pectoris,  456. 

Angiocholitis,  561. 

Angostura,  232. 

Animal  food,  bile  and,  327  ;  excess  of,  23, 
24  ;  force  production  and,  25  ;  muscular 
labor  and,  26 ;  properties  of,  23  ;  pro- 
portion of,  24 ;  tissue  formation  and, 
2$  ;  urea  and,  25  ;  vegetable  food  and, 
22  ;  viscera,  107. 

Anise,  232. 

"  Anti-fat  "  remedies,  615, 

Antiseptic  preservatives,  259. 

Apollinaris  water,  189. 


52 


783 


784 


INDEX. 


Apoplexy,  586. 

Appendicitis,  555  ;  from  grape  seeds,  166  ; 

from  soft-shell  crabs,  112. 
Appetite,  303.  369. 
Apple  sauce,  163. 
Applejack,  230. 
Apples,    162  ;  baked,  163  ;    cooked,  160 ; 

raw,  160. 
Apricots,  163. 
Arabs,  diet  of,  297. 

Arctic  expeditions,  diet  for,  271-273,  296. 
Argol,  223. 
Army  dietaries,  680. 
Army    hospital     dietaries,    British,    764 , 

French,    765  ;     Prussian,  764 ;    United 

States,  763. 
Army  prison  dietary,  688. 
Army  rations,  Austrian,  684  ;  British,  684  ; 

foreign,    764 ;     French,  765  ;     German, 

685  ;     Prussian,    685 ;    travel.     United 

States,  683. 
Aromatic  herbs,  234  ;  wines,  226. 
Arrack,  230. 
Arrowroot,  140,  777. 
Arterial  sclerosis,  456. 
Arthritis,  rheumatoid,  618. 
Artichokes,  149,  153. 
Artificial    digestion,     329 ;    infant    foods, 

721,  729  ;  human  milk,  774. 
Ascaris,  345. 
Ascites,    562 ;     dietetic    treatment,     563 ; 

pathological  physiology,  562. 
Asparagus,  154. 
Asthma,  444. 
Athletic  training,  703. 
Atrophy,  540. 
Austrian  army  ration,  684. 

Baby  foods,  130. 

Bacon,  106,  254. 

Bacteria  in  diarrhoeal  stools,  532. 

Bain  marie,  loi. 

Baking,  247  ;  powders,  123. 

Balfour's  diet  for  senile  heart,  454. 

Banana  flour,  164  ;  gruel,  165  ;  meal,  164  ; 

porridge,  165. 
Bananas,  163,  165. 

Bandaging  in  chronic  constipation,  552. 
Banting  system,  603. 
Barker,    Fordyce,    on    diet  for  puerperal 

women,  714. 
Barley,  138  ;  jelly,  779;  water,  767. 
Bathing  for  chronic  constipation,  552. 


Bauer,  on  obesity,  6<X) ;  standard  daily 
diet,  264  ;  table  of  composition  of  fruits, 
157  ;  table  of  digestibility  of  meat,  96 ; 
table  of  income  of  food  and  output  of 
waste,  336  ;  treatment  of  gastric  carci- 
noma, 527. 

Bavarian  beer,  220. 

Beans,  145  ;  kidney,  147 ;  string,  147 ; 
vanilla,  236. 

Beaujolais  228. 

Beef  broth,  103;  broth,  Scotch,  777  ;  beef, 
chipped,  96  ;  composition  of  96  ;  con- 
centrated, 96  ;  corned,  255  ;  essence, 
771  ;  extracts,  97,  99,  770  ;  fat,  96  ;  fluid 
preparations,  769  ;  jelly,  98  ;  juice,  100  ; 
lean,  96 ;  meal,  98  ;  peptone,  99  ;  pep- 
tonoids,  99;  powdered,  98  ;  predigested, 
97  ;  preparation  for  the  sick,  96  ;  preser- 
vation, 256  ;  refrigeration,  256  ;  scraped, 
97  ;  smoked,  254  ;  tea,  770  ;  tea  flavour- 
ing, 234  ;  tongue,  105. 

Beer,  219 ;  consumption,  219  ;  produc- 
tion, 219. 

Beet,  149  ;  sugar,  115,  150. 

Bellevue  Hospital  dietary,  755. 

Benger's  food,  333  ;  peptonised  jelly  98. 

Beriberi,  585. 

Bernard  on  diabetes,  632. 

Berries,  168. 

Beverages,  186,  767  ;  demulcent,  767  ;  diu- 
retic, 768  ;  in  fevers,  392  ;  in  gout,  628  ; 
nutritive,  767  ;  refrigerant,  768 ;  uses, 
187. 

Bicycling  and  digestion,  313. 

Biedert  s  cream  mixture,  774. 

Bilberries,  168. 

Bile,  327,  328. 

Bilfinger's  diet  for  neurasthenia,  581. 

Biliousness,  342,  557  ;  animal  food  and, 
559  ;  beer  and,  219  ;  causation  of,  557  ; 
dietetic  treatment,  558  ;  directions  for 
eating  in,  560  ;  symptoms  of,  557. 

Billings,  table  of  food  required  pei  diem, 
268. 

Birds'  nests,  109. 

Biscuit,  129;  meat,  773;  ship,  134. 

Blackberries,  168. 

Black  tea,  192. 

Blackwheat,  135. 

Blancmange,  774. 

Blood,  108  ;  enemata,  381  ;  water  in  the, 

34- 
Blueberries,  168. 


INDEX. 


785 


Boas's  test  for  free  hydrochloric  acid, 
492. 

Boiled  beef,  240  ;  fish,  242. 

Boiling,  240. 

Bone  marrow,  177  ;  soup  commission,  109 ; 
tissue  and  food,  2. 

Booker  on  diarrhoea,  532. 

Borax  in  foods,  260. 

Bordeaux  wine,  228,  232. 

Boric  acid  in  foods,  260. 

Bottle  feeding,  720.  • 

Bottles,  nursing,  730. 

Bouchard's  system  for  obesity,  613. 

Bouillon,  102,  772. 

Bourbon,  230. 

Bovine,  104. 

Bovinine,  103. 

Boy's  school  diet,  744. 

Brain  food,  306  ;  worker's  diet,  708. 

Bruins,  108. 

Braise,  247. 

Bran,  120  ;  bread,  656. 

Brandy,  229,  230 ;  and  egg  mixture,  775, 
776  ;  and  milk,  774. 

Brazil  nuts,  172. 

Bread,  aerated,  124  ;  baking,  121  ;  bran, 
655  ;  carbonic-acid  gas  in,  121  ;  compo- 
sition, 121  ;  compressed,  251  ;  crust, 
125  ;  dried,  251  ;  dry,  125  ;  for  school 
children,  740  ;  gluten  in,  128,  654  ;  Gra- 
ham, 125  ;  inulin,  656  ;  jelly,  779;  mak- 
ing, 120 ;  mouldy,  125  ;  quantity  con- 
sumed, 125  ;  rice,  138  ;  roll,  121  ;  rye, 
125.  129,  soya,  136,  656  ;  spoiled,  125  ; 
stuffs,  125  ;  substitutes  for,  in  diabetes, 
653;  wheaten  flour  and,  126;  whole 
meal,  127. 

Breads,  composition,  125. 

Breakfast,  299  ;  hour,  300. 

Brewing  of  beer,  2ig. 

Bright's  disease,  acute,  464  ;  chronic,  470 ; 
milk  diet,  471. 

Brine,  255. 

British  army  ration,  685  ;  army  hospital 
diet,  764  ;  commissioners  of  prisons  on 
cooking  potatoes,  148  ;  gum,  115  ;  sol- 
diers in  India,  diet  of,  297. 

Broccoli,  152. 

Broiling,  243,  244  ;  of  fat,  246. 

Bronchitis,  acute  capillary,  443  ;  chronic, 

443- 
Broncho-pneumonia,  447  ;  in  children,  448. 
Broth,    chicken,    771  ;    clam,    112  ;    diet, 


749 ;  invalid,  772  ;  meat  flavouring, 
234  ;  mutton,  106  ;  veal,  105,  771. 

Buckwheat,  135. 

Bulimia,  304,  343  ;  in  dyspepsia,  501. 

Burgundy,  225,  226,  232. 

Butter,  adulterated,  84  ;  analysis,  84 ; 
cacao,  179,  201  ;  rancid,  85. 

Butterbrod,  300. 

Butterine,  177. 

Buttermilk,  85  ;  in  diabetes,  66a 

Butternuts,  172. 

Cabbages,  151. 

Cacao,  201  ;  butter,  179 ;  inunction,  174. 

Calcium,  38-40;  oxalate  in  cabbage,  151. 

Calculi,  476  ;  biliary,  and  olive  oil,  174; 
distilled  water  for,  33. 

Calfs  liver,  108. 

California  grape  juice,  167,  188. 

Calorie,  9. 

Calories  per  pound  of  different  foods,  li  ; 
standard  of  dietaries,  692. 

Calorimeter,  9. 

Camembert,  87, 

Camplin's  bran  bread,  655. 

Cancer  of  the  stomach,  525. 

Candies,  adulteration  of,  357. 

Candy,  n6;  molasses,  116. 

Cane  sugar,  1 14. 

Canning,  257. 

Capers,  236. 

Capillary  bronchitis,  443. 

Capon,  107. 

Capri  wine,  226. 

Capsicum  annuum,  235  ;  fastigiatum,  235. 

Capsules,  gelatin,  of  cod-liver  oil,  183. 

Caramel,  115. 

Carbohydrates,  destruction  of,  17  ;  excess 
of,  in  diet,  17  ;  fats  compared  with,  17  ; 
force  production,  17 ;  metabolism  of, 
19 ;  percentage  of,  in  foods,  1 1  ;  tissue 
sparers,  18 

Carbon,  i,  2  ;  combustibility  in  different 
foods,  3  ;  consumption  of,  17  ;  in  food 
per  difm,  13;  quantity  eliminated,  13. 

Carbonic-acid  gas  in  bread,  121  ;  in  waters, 
189. 

Carcinoma  of  oesophagus,  484 ;  of  stom- 
ach, 525. 

Cardiac  disease,  450 ;  in  children,  452 ; 
palpitation,  456. 

Carnrick's  food,  81. 

Carrots,  150. 


786 


INDEX. 


Casati  on  bananas,  164. 

Casein,  in  diarrhoeal  stools,  532  ;  vegeta- 
ble, 144,  325. 

Cassava,  140.  * 

Caudle,  780. 

Cauliflower,  152. 

Caviare,  iii,  2S8. 

Cayenne,  233,  235. 

Celery,  145  ;  salt,  153. 

Cellulose,  10. 

Centenarian's  diet,  286. 

Cepe,  70. 

Cereal  milk,  132. 

Cereals  in  biliousness,  560  ;  in  constipa- 
tion, 548. 

Cerebro-spinal  meningitis,  418. 

Cetraria,  141. 

Chalybeate  waters,  191. 

Chambers's  diet  for  obesity,  613. 

Champagne,  226,  229,  232 ;  brut,  227 ; 
dryness,  227  ;  sec,  227. 

Chartreuse,  232. 

Chateau- Lafitte,  231  ;  Latour,  231  ; 
Yquem,  226. 

Cheese,  86  ;  analysis,  86 ;  Brie,  87  ;  Ca- 
membert,  87  ;  composition,  86  ;  cream, 
87 ;  Gorgonzola,  88 ;  germs  in,  88  ;  manu- 
facture, 87  ;  poisoning,  353  ;  pot,  87  ; 
Roquefort,  87. 

Chervil,  153. 

Chestnuts,  172. 

Chicken  broth,  771  ;  jelly,  773. 

Chicory,  153,  200. 

Childhood,  food  in,  283. 

Children,  constipation  in,  553;  diet  for 
school,  740  ;  dietaries  for  young,  735  ; 
dyspepsia  in,  501  ;  eczema  in,  597 ; 
food  for  young,  735  ;  hospital  dietary, 
763  ;  starchy  foods  for,  141. 

Chilies,  235. 

Chittenden,  analysis  of  pepsins,  332  •,  on 
papoid,  334 ;  on  proteids  of  corn, 
136. 

Chloride  of  sodium,  39. 

Chlorosis,  458. 

Chocolate,  201,  203,  204 ;  for  children, 
204 ;  for  invalids,  205 ;  habit,  204 ; 
preparations,  204  ;  uses,  204. 

Cholera,  420  ;  dietetic  prophylaxis,  420  ; 
milk  infection,  361  ;  symptoms  and 
treatment,  421. 

Cholera  infantum,  535  ;  morbus,  536. 

Chops,  245. 


Chorea,  583. 

Chossat's  experiments  with  starving  ani- 
mals, 275. 

Chrystie's  table  of  infant  feeding,  729. 

Church?8  table  of  fooa  equivalents,  338. 

Cider,  232. 

Circulation  and  diabetes,  639  ;  and  diges- 
tion, 308. 

Cirrhosis,  561  ;  with  ascites,  562  ;  without 
ascites,  563. 

Citron,*i69. 

Clams,  112. 

Claret,  224,  228,  229,  231. 

Clark's  corn  statistics,  136  ;  rice  statistics, 
137- 

Claviceps  purpurea,  355. 

Climate,  296  ;  and  alcohol,  213. 

Clothing  and  food,  295. 

Cloves,  236. 

Coca  wine,  225. 

Cocoa,  201  ;  adulteration,  203  ;  butter, 
202  ;  composition,  202  ;  nibs,  203  ;  pow- 
ders, 203  ;  preparation,  202  ;  uses,  202. 

Cocoanut  oil,  179. 

Cocoanuts,  172. 

Codfish,  dried,  no,  in. 

Cod-liver  oil,  180,  181  ;  capsules,  183 ; 
chemical  properties,  180 ;  chronic  dis- 
eases and,  185  ;  dosage,  181  ;  emulsions, 
182 ;  inunction,  174 ;  marasmus  and, 
185  ;  methods  of  administration,  182  ; 
physical  properties,  182  ;  substitutes  for, 
184  ;  tuberculosis  and,  433  ;  uses,  184. 

Coffee,  196,  260  ;  adulteration,  200  ;  com- 
position, ig6  ;  decoction,  197  ;  diuretic 
action,  ig8,  199 ;  filtration,  197  ;  good 
effects,  198  ;  gout  and,  628  ;  habit,  199  ; 
influence  on  gastric  digestion,  194  ;  in- 
fusion, 197  ;  ill  effects,  199 ;  isinglass 
and,  781  ;  physiological  action,  198  ; 
preparation,  197  ;  substitutes  for,  200 ; 
tea  compared  with,  201. 

Cognac  mixture,  775. 

Cold  drinks,  308  ;  food,  308. 

Colitis,  chronic,  537. 

Colostrum,  53,  719. 

Commercial  life,  diet  for,  711. 

Concentrated  food,  251. 

Condensed  foods,  249. 

Condensed  milk,  81,  721  ;  formula,  82  ; 
unsweetened,  82. 

Condiments,  186 ;  harmful  effects,  233 ; 
properties,  233  ;  uses,  233. 


INDEX. 


787 


Conditions  which  especially  affect  diges- 
tion, 299. 

Consomni^,  772. 

Constipation,  chronic,  545  ;  aids  to  dietetic 
treatment,  550 ;  bandaging,  553  ;  die- 
tetic treatment,  548  ;  electricity  in,  552  ; 
foods  forbidden,  550,  554;  foods  recom- 
mended, 554  ;  fruits  for,  159;  in  infants 
and  children,  553 ;  massage  in,  551  ; 
medicines  for,  552  ;  pathological  physi- 
ology, 546  ;  prunes  for,  167  ;  summary 
of  useful  articles  for,  550 ;  symptoms, 
547  ;  tobacco  in,  552. 

Convalescence,  receipts  suitable  for,  767. 

Convalescent  diet  in  hospitals,  747  ;  fever 
diet,  395  ;  in  typhoid  fever,  406. 

Cook  on  the  dietetic  habits  of  the  Eskimo, 
292. 

Cook  County  Hospital  dietary,  758. 

Cooking,  238 ;  for  diabetics,  657 ;  of  eggs.go; 
of  fish,  248  ;  of  vegetables,  24S  ;  uses,  239. 

Corn,  136  ;  as  a  vegetable,  139. 

Cornstarch,  777. 

Cornaro's  diet  to  prolong  life,  276. 

Corpulence,  dietaries  for,  605. 

Count  Rumford,  241. 

Cows  best  adapted  for  modified  milk,  80. 

Crabs,  112. 

Cracker  gruel,  779. 

Crackers,  133  ;  Boston,  125  ;  composition, 
125  ;  Craham,  125  ;  oatmeal,  125  ;  oys- 
ter, 125  ;  pilot,  125 ;  soda,  125. 

Cranberries,  155. 

Cream,  45,  82  ;  centrifugal,  83 ;  cheese, 
86,  87 ;  clotted,  83  ;  composition,  45  ; 
condensed,  83  ;  Devonshire,  83  ;  evap- 
orated, 83  ;  ice,  84 ;  mixture,  Bicdert's 
poisoning.  353  ;  uses,  83,  84. 

Cream  of  tartar  drink,  768. 

Cress,  152. 

Crime  and  famine,  277,  281. 

Crimping  fish,  ill. 

Cruciferae,  151. 

Crustaceans,  112. 

Cucumbers,  153. 

Cuisine,  176. 

Cura9oa,  232. 

Cure,  dry,  702  ;  fruit.  699  ;  grape.  699  ; 
meat  and  hot  water,  701 ;  milk,  44 ; 
phthisis,  440  ;  rest,  578  ;  whey,  697. 

Currants,  168  ;  dried,  160. 

Curry  powders,  233. 

Custard,  92  ;  savoury,  776. 


Dahi,  361. 

Daily  dietary,  264-266. 

Dandelion  roots,  1S8  ;  tops,  152. 

Darby's  fluid  meat,  98. 

Dates,  169  ;  dried,  160. 

Delirium  tremens,  367  ;  treatment,  367. 

De  Long  expedition,  daily  diet  table  of, 
271. 

Dementia,  587. 

Demulcent  beverages,  767. 

Dencke's  table  of  infant  feeding,  726. 

Dentition,  abnormal,  481. 

Desiccation,  249. 

Desserts  for  children,  738. 

Deutero-albumose,  325. 

Devilled  foods,  108. 

Dextrin,  113,  115,  123,  330. 

Diabetes  mellitus,  631  ;  beverages,  658 ; 
causation,  633  ;  circulation  and,  639  ; 
course,  644 ;  diagnosis,  645  ;  Diiring's 
diet,  661  ;  Ebstein's  diet,  661 ;  foods 
allowable,  651;  foods  forbidden,  653; 
frequency,  633  ;  gout  and,  634  ;  hunger 
in,  642  ;  hygienic  treatment,  661  ;  late 
symptoms,  643  ;  medical  treatment,  662 ; 
nature  of,  631 ;  Naunyn's  diet,  661  ; 
nervous  system  and,  638  ;  overeating, 
633 ;  physiological  experiments,  635  ; 
prognosis,  645  ;  prophylaxis,  646  ;  sub- 
stitutes for  sugar  in,  675  ;  symptoms, 
640  ;  thirst  and,  640 ;  treatment,  646 ; 
various  theories  of,  639.' 

Diabetic  urine,  641. 

Diarrhoea,  529  ;  dietetic  treatment,  529  ; 
examination  of  the  stools,  532 ;  in  in- 
fants, 530 ;  in  young  children,  530 ; 
pathological  physiology,  529  ;  red  wines 
in,  228  ;  summer,  534. 

Diarrhoea,  chronic,  in  children,  539> 

Diastase,  330. 

Diet,  alimentary-canal  diseases  and,  481  ; 
anaesthetics  and,  675  ;  arctic  expedi- 
tion, 271-273,  296 ;  average  daily,  for 
adult,  266  ;  blood  diseases  and,  450 ; 
brain  workers,  708  ;  circulatory  system 
and,  450;  commercial  life  and,  7"  i 
concentrated  fowls,  251  ;  convalescent 
fever,  395  ;  convalescent  typhoid  fever, 
406  ;  Cornaro's.  276  ;  cures  for  phthisis, 
440  ;  dry,  449,  454  ;  exclusive  milk,  43  ; 
fever  in  general  and,  387  ;  heredity  and, 
2gi  ;  improperly  balanced  ingredients 
of,  281  ;  in  disease,  387  ;  infectious  dis- 


788 


INDEX. 


eases  and,  387^  kitchen  outfit,  386 ; 
leanness  and,  615  ;  liver  diseases  and, 
557  :  method  of  adapting,  for  the  sick, 
339 ;  milk,  in  tuberculosis,  437  ;  milk, 
in  typhoid  fever,  398  ;  miscellaneous  dis- 
eases and,  371  ;  mixed,  26  ;  monotony  of, 
305  ;  nervous-system  diseases  and,  569  ; 
occupation  and,  707 ;  pancreatic  dis- 
eases and,  568  ;  prison,  688  ;  puerperal 
women  and,  714;  race  and,  291  ;  respi- 
ratory-system diseases  and,  440  ;  school 
children's,  740 ;  standard  daily  work, 
264  ;  starvation,  279,  280 ;  travel  and, 
712  ;  Tufnell's  457  ;  urinary-system  dis- 
eases and,  463  ;  variety  in,  305  ;  vege- 
tarian, 30. 

Dietaries,  680,  659 ;  army  hospital,  763  ; 
for  young  children,  732  ;  hospital,  750  ; 
standard,  12,  264,  265  ;  weight  of  nutri- 
ents in,  12. 

Dietetic  breads,  127 ;  causes  of  disease, 
339,  341  ;  complications  from  associated 
diseases,  673. 

Digestibility,  comparative,  of  meats,  95  ; 
of  nutrients,  21. 

Digestion,  307,  316  ;  alcohol  and  gastric, 
211  ;  artificial,  329  ;  circulation  and, 
308 ;  conditions  especially  affecting, 
299  ;  duration  of  gastric,  322  ;  exercise 
and,  312  ;  external  heat  and,  309 ;  in 
the  intestine,  326 ;  in  the  mouth,  316  ; 
in  the  stomach,  317;  of  fats,  328;  of 
food,  299 ;  of  proteids  in  the  stomach, 
325  ;  salivary,  317  ;  sleep  and  rest  and, 
313  ;  temperature  and,  313. 

Digestive  ferments,  329. 

Dilatation  of  the  stomach,  511 ;  dietetic 
treatment,  511  ;  electricity  for,  511  ; 
lavage,  513  ;  massage,  516  ;  pathological 
physiology,  511. 

Dinner,  299  ;  hour,  3CX3. 

Diphtheria,  414;  feeding  in,  315;  paraly- 
sis in,  418. 

Diseases,  diet  in,  450 ;  caused  by  dietetic 
errors,  341,  399 ;  especially  influenced 
by  diet,  599 ;  of  the  alimentary  canal, 
481  ;  miscellaneous,  671  ;  of  the  blood, 
458 ;  of  the  circulation,  450 ;  of  the 
heart,  450 ;  of  the  intestines,  529 ;  of 
the  liver,  557  ;  of  the  mouth,  481 ;  of 
the  nervous  system,  566  ;  of  the  oesopha- 
gus, 484  ;  of  the  pancreas,  568  ;  of  the 
stomach,485;  of  the  urinary  system,  463. 


Disinfection  of  utensils,  374. 

Disordered  sleep,  582. 

Diuretic  beverages,  768. 

Donkin's  diet  for  diabetes,  659. 

Dough,  122,  129. 

Doura,  135. 

Dried  dates,  160 ;  fruits,  254 ;  vegetables, 
250. 

Drink,  excess  of,  343. 

Drinks,  effervescing,  189. 

Drugs  in  human  milk,  718. 

Dry  diet  cure,  702  ;  for  the  senile  heart, 
449.  454  ;  Tufnell's,  457. 

Drying  of  food,  249,  253. 

Duck,  107. 

Duckworth,  Sir  Dyce,  on  gout,  624,  628. 

Dujardin-Beaumetz,  average  daily  dietary, 
266  ;  grog  de  la  poudre  de  viande,  99  ; 
treatment  of  dyspepsia,  499  ;  system  for 
obesity,  612. 

Diiring's  diet  for  diabetes,  661. 

Dysentery,  acute,  543  ;  chronic,  544. 

Dyspepsia,  485  ;  alcohol  in,  217  ;  anaemia 
and,  501 ;  atonic,  5C0 ;  beverages  for, 
498  ;  bulimia  and,  501  ;  children  with, 
501  ;  desirable  foods  for,  497  ;  dietetic 
treatment,  496 ;  Dujardin-Beaumetz's 
treatment,  499 ;  flatulency  and,  500 ; 
foods  forbidden  in  all  cases,  496  ;  foods 
allowable,  497 ;  gout  and,  501  ;  hyper- 
acidity and,  500  ;  irritative,  500  ;  Leube's 
treatment,  499  ;  lules  for  special  vari- 
eties, 500  ;  See's  treatment,  499  ;  sys- 
tems of  treatment,  498. 

Dyspeptics,  general  rules  for,  499. 

Dysphagia,  483. 

Ebstein,  diabetic  diet,  660  ;  on  gout,  623  ; 
on  obesity,  604. 

Economic  value  of  foods,  19,  21. 

Eczema,  594 ;  children  and,  597  ;  insuffi- 
cient food  and,  595  ;  nursing  infants 
and,  596 ;  overeating  and,  595  ;  shellfish 
and,  113  ;  typical  diet  for,  594. 

Eels,  no. 

Effervescing  waters,  188. 

Egg  albumen,  90 ;  brandy  and,  775,  776 ; 
composition  of  a  hen's,  89  ;  prepara- 
tions, 775  ;  wine  and,  775. 

Eggnog,  90,  775. 

Eggplant,  153. 

Eggs,  89,  178,  250,  257;  absorption,  89 ; 
boiled,    91 ;     cooking,    90 ;    dried,    92  ; 


INDEX. 


789 


enemata  of,  381 ;  freshness,  90  ;  gout 
and,  625  ;  in  fever,  391  ;  in  tubercu- 
losis, 432  ;  plover's,  178  ;  preservation 
of,  92,  256  ;  raw,  90  ;  scrambled,  92. 

Einhom's  gastric  electrode,  517;  stomach 
bucket,  489. 

Elderberry,  169. 

Electricity  for  gastric  dilatation,  517  ;  in 
chronic  constipation,  552. 

Elements,  chemical,  i ;  analysis  of,  in 
foods,  4 ;  quantity  of,  in  standard  diets, 
16. 

Embi^onine,  655. 

Emphysema,  445. 

Empyema.  449. 

Endive,  153. 

Enemata,  nutrient,  375  ;  aids  to  retention. 
378  ;  composition  of,  380 ;  methods  of 
injection,  377  ;  opium  in,  379  ;  pancreas 
and  meat,  773. 

Energy  from  food,  7  ;  sugar  and,  114. 

English  army  ration,  684  ;  hospital  diet- 
ary for  children,  762  ;  walnuts,  171. 

Enteralgia,  572. 

Enteritis,  acute  catarrhal,  536 ;  chronic, 
470,  536  ;  membranous,  541. 

Enterocolitis  in  infants  and  children,  534  ; 
chronic,  539  ;  dietetic  treatment,  534  ; 
prevention,  534. 

Epilepsy,  583. 

Erbswurst,  146. 

Ergotism,  355. 

Erysipelas,  419. 

Erythema,  592. 

Escherich  on  diarrhoea!  stools.  532,  533. 

Eskimo,  dietetic  habits  of,  292,  342. 

Ewald,  test  for  motor  power  of  stomach, 
494. 

Exclusion  of  air  from  food,  257. 

Exercise  and  digestion,  312 ;  for  school 
children,  740. 

Exophthalmic  goitre,  672. 

Extracts,  249 ;  of  beef,  98  ;  of  pancreas, 
68,  332. 

Extractum  camis,  103. 

Famine,  281  ;  crime  and,  277.  281. 

P'arina,  133. 

Farinaceous  diet  in  hospitals,  747 ;  gruels 

in  typhoid  fever,  401. 
Farinaceous  foods,  prepared,  130. 
Fasting    by    Eskimos,    294 ;     girls,    276 ; 

hysteria  and,  276. 


Fat,  albumen  compared,  27 ;  beef,  177 ; 
diarrhoea!  stools  and,  532 ;  estimation 
of,  in  milk.  50 ;  of  cream,  83 ;  of  pork, 
177  ;  storage,  27. 

Fatigue  and  food.  313. 

Fats,  animal,  176  ;  cooked,  175  ;  corrosive 
poisons,  and,  175  ;  dietetic  uses,  179  ; 
digestibility,  174;  digestion  of,  328; 
diseases  in  which  fats  are  forbidden, 
179 ;  diseases  in  which  fati^  are  useful, 
179;  excess  of,  175;  gout  and,  626; 
heat  producers,  16  ;  laxative  action,  180  ; 
of  milk,  45  ;  percentage  of,  in  foods,  1 1  ; 
tuberculosis  and,  433;  uses  of,  173; 
vegetable,  178. 

Feeding,  forced,  439,  588 ;  helpless  pa- 
tients, 372  ;  hypodermic,  383  ;  intravas- 
cular, 383  ;  irregularity  in,  370  ;  of  in- 
fants, 263,  719 ;  rectal,  375  ;  sleep  and, 
373  ;  the  sick,  369  ;  through  gastric  fis- 
tula, 4S4  ;  unconscious  patients,  374 ; 
young  children,  734. 

Ferments,  329  ;  in  food,  253. 

Fever,  alcohol  in,  215  ;  beverages  in,  392  ; 
convalescent  diet  in,  395  ;  diet  in,  387  ; 
intermittent,  426  ;  malarial,  426  ;  patho- 
logical physiology,  387  ;  receipts  suitable 
for.  767  ;  remittent,  427  ;  scarlet,  411  ; 
typhoid,  397  ;  typhus,  410. 

Field  ration.  682. 

Fig  wine,  232. 

Figs,  160,  169. 

Filbert,  172. 

Fining  of  wines,  224. 

Fish,  no;  desiccated,  in  ;  diet,  111,749; 
digestibility  of,  in;  dried,  ni,  250; 
fat.  178  ;  frozen,  255  ;  gout  and,  625  ; 
oils,  178;  poisoning,  353;  roc,  in; 
smoked,  in. 

Fistula,  gastric,  484. 

Flavouring  fluid  food,  I02. 

Flaxseed  tea,  768. 

Flies,  infection  of  food  by,  363. 

Flour,  118;  balls,  131  ;  banana,  164;  de- 
corticated, 128  ;  rice,  124  ;  wheat,  126. 

Fluid,  hot,  310  ;  iced,  310;  meat,  98. 

Food,  absorption,  334  ;  age  and,  283  ;  ad- 
ministration  of,  for  the  sick,  369  ;  adult 
life  and,  284 ;  adulteration,  356 ; 
amount  required  per  diem,  267-269 ; 
amesthctisation  and  674 ;  antiseptics 
in,  259;  artificial.  729  ;  Hengcr's,  132; 
body  heat  and,  311  ;  body  weight  and. 


790 


INDEX. 


289 ;  Camrick's,  81,  133 ;  childhood 
and,  263  ;  classification,  4 ;  climate 
and,  296  ;  concentration,  104,  249  ;  cost 
of,  19 ;  daily  allowance,  14 ;  death 
from  lack  of,  9  ;  details  of  serving,  370  ; 
dextrinised,  132  ;  digestion,  299  ;  eco- 
nomic value  of,  19,  21  ;  enemata,  375, 
382  ;  energy  from,  7  ;  equivalents,  267, 
268,  337 ;  Eskimos',  293  ;  evaporated, 
132  ;  excess  of,  342  ;  exercise  and,  312  ; 
farinaceous,  with  malt,  131  ;  farinaceous, 
receipts  for,  767  ;  fatigue  and,  313  ;  fe- 
ver and,  387;  flavouring  fluid,  102  ;  for 
special  conditions,  283  ;  for  young  chil- 
dren, 735  ;  frozen,  255  ;  general  rela- 
tion to  special  diseases,  339 ;  hypoder- 
mic injections  of,  383  ;  ideal  ration  of 
fluid,  265  ;  ideal  ration  of  solid,  265  ; 
idiosyncrasies,  364 ;  improperly  bal- 
anced ingredients  of,  344  ;  income  of, 
336  ;  individual  size  and,  289 ;  infants 
and,  732 ;  infection  through  flies,  363  ; 
insufficient,  342  ;  insomnia  and,  315  ; 
in  the  mouth,  316  ;  in  the  stomach,  317  ; 
inunctions,  382  ;  lactated,  81  ;  medi- 
cines and,  383,  385  ;  Mellin's,  132  ; 
micro-organisms  in,  360 ;  minimum 
amount  for  difl"erent  ages,  383  ;  modifi- 
cations produced  in  urine  by,  463  ; 
mineral,  for  daily  use,  270;  Nestle's, 
81,  133  ;  old  age  and,  285  ;  parasites 
and,  344 ;  preservation,  253  ;  propor- 
tion of  carbohydrates,  267,  269,  270 ; 
proportion  of  proteid,  267,  269 ;  pur- 
veyors, training  of,  386  ;  ptomaines  in, 
350 ;  quantity  eaten  in  lifetime,  274  ; 
quantity  for  the  sick,  270  ;  quantity  re- 
quired, 261 ;  raw,  293  ;  receipts,  767  ; 
rest  and,  313  ;  season  and,  296 ;  sex 
and,  290;  sleep  and,  313,  314  ;  substi- 
tutes' for,  260 ;  suppositories,  382  ; 
teething  and,  739  ;  temperature  of,  308, 
309  ;  undigested,  329  ;  vegetable,  143. 
Foods,  albuminoid,  5  ;  amylaceous,  113, 
119;  animal,  4,  41  ;  animal,  in  bilious- 
ness, 559  ;  animal  and  vegetable  com- 
pared, 22;  azotised,  5;  baby,  130; 
brain,  20  ;  calorifacient,  5  ;  cereal,  118  ; 
classes  of,  30 ;  complete,  4  ;  composi- 
tion of  common,  6  ;  duration  of  diges- 
tion of  different,  322  ;  elementary  com- 
position, I  ;  farinaceous,  113,  119 ; 
fatty,    176,   178 ;    force    producers,   6  ; 


force-producing  value  of  different 
classes,  15  ;  heat  givers,  20 ;  infant, 
130;  Liebig's,  131;  material  for  mus- 
cles, 20;  military  pea,  146  ;  nei"ves  and, 
30 ;  nitrogenous,  5  ;  non-nitrogenous, 
5  ;  order  of  taking,  299  ;  pancreatin- 
ised.  333  ;  peptonised,  333  ;  prepared 
farinaceous,  130,  133  ;  relative  value  of, 
20  ;  respiratory,  5  ;  salts  of,  38  ;  special 
conditions  and,  283  ;  starch  percentage 
in  vegetable,  119;  starchy,  118;  stimu- 
lating, 20  ;  tissue  formers,  5  ;  vegetable, 
4  ;  vegetable,  in  biliousness,  560  ;  water 

in,  34- 

Foot-and-mouth  disease,  363. 

Foot-ball-team  diet,  707. 

Foot  tons  of  engine  compared  with  body, 
8  ;  heat  and.  7  ;  latent  energy  and,  8  ; 
per  diem,  7,  12,  14  ;  potential  energy  in 
diff'erent  dietaries,  22. 

Force  production,  7 ;  of  diff'erent  classes 
of  foods,  15. 

Forced  feeding,  439,  588. 

Fordham  Hospital  dietary,  755, 

Foreign  bodies  swallowed,  484. 

Fothergill's  amylaceous  food,  779. 

Fowl,  107. 

Freezing  food,  255. 

French  army  hospital  diet,  765  ;  army  ra- 
tion, 680 ;  Cognac,  230. 

Fresenius's  tabletof  fruit  composition,  157. 

Fruit,  biliousness  and,  560 ;  constipation 
and,  548,  549  ;  diabetes  and,  652,  653  ; 
essences,  188  ;  gout  and,  627  ;  poison- 
ing, 159  ;  sirups,  188. 

Fruits,  acids  of,  156  ;  antiscorbutic  use  of, 
158  ;  candied,  113 ;  classification  of, 
156  ;  composition  of,  157  ;  cooked,  159  ; 
daily  diet  of,  159;  digestibility,  160; 
diuretic  use  of,  158  ;  dried,  160  ;  flavour 
of,  156  ;  glucose  in,  116  ;  laxative  action, 
158, 161 ;  organic  acids,  156  ;  pectin,  156; 
properties,  158;  ripening,  159;  soups, 
160  ;  sugar,  114,  117,  157  ;  table  of  com- 
position, 157  ;  uses,  158  ;  varieties,  161 ; 
water  in,  158  ;  when  to  eat,  159. 

Frying,  246. 

Full  diet,  748. 

Functional  albuminuria,  466. 

Fungi,  169;  poisonous,  171. 

Fungus,  of  ergot,  355  ;  yeast,  205. 

Furunculosis,  598. 

Fusel  oil,  229,  231. 


INDEX. 


791 


of, 


Gaduin,  180. 

Gall  ducts,  acute  inflammation  of,  561 

Gallstones,    565  ;    dietetic    treatment 
567  ;  olive  oil  for,  174. 

Game,   107,  246;   "lugn,"  246,  351;  poi- 
soning, 351,  355.    7 

Garlic,  154.  / 

Garrod  on  gout,  624/;   theory  of  scurvy, 

669.  / 

Gases,  of  indigestion,;  486  ;  intestinal,  329. 
Gastralgia,  571.         / 
Gastric   catarrh,    acute,    502 ;     causation, 

502  ;  convalescerice,   504 ;    in   children, 

504;  symptoms,' 502 ;  treatment,  502. 
Gastric   catarrh,   chronic,   causation,  505 ; 

convalescence,  ^09  ;  dietetic  treatment, 

506  ;  electricity  I  for,   5 10  ;  exercise   for, 

510;    in   childien,    510;     hydrochloric 

acid   for,    509  ;i  lavage,    510;    massage, 

510;  milk  die|,  506  ;  other  diets,   507; 

pathological  physiology,  505. 
Gastric  digestion^  317;  alcohol  and,  211  ; 

duration,  322.1 
Gastric  juice,  31I3,  491  ;  abnormalities  of, 

326  ;  absence  \>{  hydrochloric  acid,  326  ; 

hyperacidity,  326  ;  hypersecretion,  326, 

493-,    secretion   of,   319;    fistula,    484; 

fever  in  children,  504  ;  ulcer,  523. 
Gastritis,  chronic,  505. 
Gastro-intestinal  catarrh,  chronic,  539. 
Gastro-enteritis,  chronic  pseudo,  541. 
Gelatin,    108,   325  ;  capsules  of  cod-liver 

oil,  183  ;  in  fever,  392  ;  milk  and,  67  ; 

preparations  of,  780. 
Geneva  gin,  230. 
German  army  ration,  684. 
Germs  in  food,  253,  260. 
Gin,  229,  230. 
Ginger,  236  ;  ale,  188. 
Glucose,  116. 
Gluten,    325 ;    bread,    128,    654 ;    casein, 

121  ;  fibrin,  121  ;  flour,  654  ;  vegetable, 

144. 
Glutin,  121. 
Gluttony,  261. 
Glycerin,    180 ;      laxative     action,     180 

mouth  wash,  37. 
Glycogen,  18. 
Glycosuria,  114. 
Gonorrhoea,  481^ 
Goose,  107. 

Gooseberries,  168,  169. 
Gorgonzola,  88. 


Gout,  aids  to  dietetic  treatment,  631  ; 
beverages  and,  628;  causation,  619; 
chronic,  624  ;  diabetes  and,  634 ;  die- 
tetic treatment,  622  ;  preventive  treat- 
ment, 62'i  ;  saline  waters,  630 ;  symp- 
toms, 621 ;  theory  of  dietetic  treatment, 
622. 

Gouty  diathesis,  624. 

Gouverneur  Hospital  dietary,  755. 

Graham  bread,  125  ;  crackers,  125, 

Grain  poisoning,  354. 

Granum,  130. 

Grape  cure.  699  ;  must,  221. 

Grapes,  166;  sugar  in,  114,  116. 

Gravel,  478. 

Greely  expedition,  diet  in,  272  ;  diet  for 
arctic  expedition,  table  of,  274. 

Green  tea,  192  ;  vegetables,  151. 

Greens,  144. 

Grilling,  243. 

Groats,  Scotch,  139 

Grocer's  itch,  115. 

Grog  de  la  poudre  de  viande,  99. 

Ground  pear,  149. 

Grouse,  107. 

Gruel,  banana,  165  ;  cracker,  779  ;  Indian 
meal,  779  ;  milk,  69  ;  oatmeal,  777  ;  re- 
ceipts for,  777  ;  rice,  778  ;  typhoid  fever 
and,  401. 

Gruy^re,  88. 

Guinea-worm  disease,  345. 

Gum  in  fruits,  157. 

GQnzberg's  lest  for  free  hydrochloric  acid, 
492. 


Habit  in  children's  diet,  745. 

Haemoptysis,  442. 

Ham,  106. 

Hard-labour  prison  diet,  262. 

Hard-tack,  134. 

Haricots,  147. 

Harlem  Hospital  dietary.  755. 

Hartwell  on  athletic  training,  707. 

Hash,  240. 

Hasheesh  and  fasting,  261. 
,»  ^^HarT  disease,  diet  in,   108,  450;  senile, 
^    diet  for,  453. 

Heat,  external,  and  digestion,  309. 

Haemorrhage  of  the  lungs,  443. 

Hrcmorrhagic  purpura,  67 1. 

Hscmorrhoids,  555. 

Hepatalgia,  572. 

Herb  teas,  188. 


792 


INDEX. 


Herbs,  aromatic,  237. 

Heredity  and  diet,  291. 

Hetero-albumose,  325. 

Hindu,  diet  of  the,  296. 

Hock,  229. 

Hoff's  Malt  Extract,  143. 

Holland  gin,  230. 

Holt,   dietaries  for  young  children,  738  ; 

formul?e    for    infant    feeding,  727 ;   on 

weaning,  724. 
Honey,  117. 
Hop  extracts  219. 
Horseradish,  237. 
Hospital  dietaries,  750. 
Hospitals  for  children,  dietaries  of,  762, 

763. 

Hot  drinks,  308,  310 ;  fluids,  310 ;  food, 
308  ;  water  cure,  701. 

Hours  for  meals,  299 ;  for  children's 
meals,  741. 

House  diet,  748. 

Huckleberries,  168. 

Human  milk,  analysis,  47  ;  artificial,  77  ; 
-     drugs  in,  48,  718. 

Humphrey's  diet  of  centenarians,  286 ; 
report  upon  centenarians,  286. 

Hunger,  279,  315;  in  diabetes,  642;  rec- 
tal feeding  and,  316. 

Hydrochloric  acid,  320 ;  absence  of,  326 ; 
Boas  test  for,  492 ;  calcium-carbonate 
test  for,  492  ;  free,  491  ;  gastric  catarrh 
and,  509  ;  Gunzberg's  test  for,  492. 

Hydrogen,  i,  2  ;  combustibility  in  foods, 
3  ;  in  iocA  per  diem,  13  ;  quantity  elimi- 
nated, 13. 

Hyperacidity  of  gastric  juice,  326. 

Hypersecretion  of  gastric  juice,  326. 

Hypodermic  feeding,  385. 

Ice,  37  ;  cracked,  37  ;  purity,  31. 

Ice-cream  poisoning,  353. 

Iced  fluids,  310. 

Iceland  moss,  41,  171. 

Ideal  ration  of  liquid  food,  265  ;  of  solid 

food,  265. 
Idiosyncrasies  in  regard  to  food,  364 ;  of 

dyspeptics,  487. 
Immermann,  theory  of  scurvy,  669. 
Imperial  drink,  768. 
Imperial  Granum,  130. 
Inanition,  274. 
Indian  corn,  136. 
Indigestion,  485  ;  chronic,  in  children,  538. 


Infant  feeding,  263,  718. 

Infant  feeding  tables,  727  ;  Chrystie's,  729 ; 

Dencke's,    726 ;    Holt's,  729  ;    Purdy's, 

727  ;  Rotch's,  727  ;  Starr's,  726,  728. 
Infant  stomach,  size  of,  718. 
Infants,  eczema  in,  596. 
Infants,  premature,  732  ;  weighing  of,  731. 
Inflammations,  surgical,  678. 
Influenza,  413. 

Injuries,  surgical,  diet  after,  676. 
Insane,  dietary  for  the,  587. 
Insanity,  587  ;  from  hunger,  279. 
Insomnia,  582  ;  and  food,  315. 
Intermittent  fevers,  426. 
Intervals  of  infant  feeding,  720. 
Intestinal  antisepsis  in  typhoid  fever,  404  ; 

catarrh,    537  ;     catarrh,    chronic,    539 ; 

gases,    329 ;     indigestion,     chronic,    in 

children,  538 ;  obstruction,  acute,   544  ; 

worms,  345. 
Intestine,  food  in  the,  326. 
Intravascular  feeding  in,  416. 
Inunction  foods,  382. 
Inulin  bread,  656. 
Invalid  ration  too  low  in  carbohydrates, 

375  ;  in  proteid,  265. 
Irish  whiskies,  230. 
Iron,  2,  41  ;  ration,  146. 
Isinglass,  108. 

Jam,  168. 

Jaundice,  catarrhal,  561. 

Jeannette  expedition,  starvation,  279. 

Jeff"ries's  gluten  bread,  654. 

Jellies,  no. 

Jelly,  barley,  779  ;  bread,  779 ;  calfs-head, 

109 ;     calfs-foot,    109 ;     chicken,    773 ; 

currant,  768. 
Jerusa'em  artichokes,  149. 
Jessen's  table  of  digestibility  of  meat,  95, 

96. 
Jockeys'  training  diet,  707. 
Johannisberg  wine,  225. 
Johannis  water,  1S9. 
Johns  Hopkins  Hospital  dietary,  758. 
Johnson's  fluid  beef,  103. 
Jones,  Bence,  on  gout,  624. 
Jones's  method  of  meat  preservation,  260, 
Juice,  beef,  769  ;  100  ;  clam,  112. 
Junket,  64. 

Kava,  206. 

Keating's  diet  for  neurasthenia,  581. 


index; 


793 


Kefir  ferments,  72. 

Kepler's  malt  extract,  143. 

Kidney  beans,  147. 

Kidneys,  108. 

Kindermilch,  333. 

Kirscb,  230. 

Klemperer's  test  for  motor  power  of  stom- 
ach, 495. 

Kneipp  system,  699. 

Kohl  rabi,  150. 

Kola,  205  ;  composition,  205 ;  infusion, 
205  ;  uses,  205. 

Konig,  analysis  of  grape  must,  221  ;  com- 
position of  coffee,  196  ;  composition  of 
mushrooms,  etc.,  170. 

Koumiss,  6g ;  composition,  71  ;  cure,  71  ; 
diabetes  and,  660  ;  ferment,  70  ;  home- 
made, 70,  775  ;  manufacture  of,  69 ; 
properties,  70;  sterilised,  73. 

Koumysgen,  71. 

Kronenquelle  water,  190. 

Kulz's  inulin  biscuits,  656. 

Kummel,  232. 

Kumyss,  69  (see  Koumiss). 

Kussmaul's  method  of  lavage,  513. 

Laboratories,  milk,  78. 

Labour  and  food,  262. 

Lachrymoe  Christi,  225. 

Lactalbumin,  46. 

Lactated  food,  81. 

Lactic  acid,  46. 

Lactometer,  50. 

Lacto-preparata,  81. 

Lactose,  117  ;  estimation  of,  in  milk,  51. 

Lamb,  106. 

Landois  and  Stirling,  table  of,  267. 

Laparotomy,  diet  after,  677. 

Lard,  176. 

Laryngismus  stridulus,  441. 

Laryngitis,  tubercular,  441. 

Lathyrism,  355. 

La  Trappe  monks,  dietetic  habits  of,  302. 

Lavage,  513  ;  in  gastric  carcinoma,  528. 

Lead  poisoning,  358  ;  chronic,  672. 

Leanness,  615. 

Leaven,  122. 

Lebert's  milk  cure,  437. 

Leeks,  154. 

Legumes,  145. 

Legumin,  69,  144,  655. 

Lemon,  161  ;  ice,  162  ;  juice,  161. 

Lemonade,    161,    188,    768 ;   effervescing, 


768  ;  in  fever,  392  ;  substitutes  for,  188  ; 
with  eggs,  776  . 

Lenten  fasting,  277. 

Lentils,  145,  147. 

Letheby,  oatmeal  analysis,  140. 

Lettuce,  152. 

Leube's  test  for  motor  power  of  the  stom- 
ach, 494  ;  treatment  of  dyspepsia,  499. 

Levulose,  117, 

Leyden's  diet  for  neurasthenia,  580. 

Lichen,  171. 

Liebig-Horsford  baking  powders,  123. 

Liebig's  extract  of  meat,  103  ;  foods,  131. 

Life  ration,  13. 

Lima  beans,  147. 

Lime,  38, 39;  saccharated,67  ;  water,  775. 

Lime  juice,  i6i  ;  biscuit,  39. 

Limes,  161. 

Linseed  tea,  768. 

Lipanin,  184,  220. 

Liqueurs,  232 

Liquor,  consumption  of,  219 ;  pancreati- 
cus,  333. 

Liquors,  229. 

Litterateur,  diet  for,  708. 

Litha;mia,  478. 

Liver,  108  ;  abscess,  565  ;  amyloid,  564  ; 
diseases  of  the,  557  ;  fatty,  564  ;  syphi- 
lis, 565. 

Liverjwol  Hospital  dietary,  758. 

Lobsters,  112. 

Locomotor  ataxia,  586. 

Loeflund's  Malt  Extract,  143. 

Lupulin,  220. 

Macaroni,  134  ;  boiled,  780. 

Macaroons,  171. 

Mace,  236. 

Madeira,  225,  226,  232. 

Maize,  136. 

Malaga,  225,  226. 

Malarial  fever,  426. 

Malmsey,  225. 

Malt,   142,    330 ;   cod-liver  oil   and,  184 ; 

extracts,  142  ;  flour,  142  ;  food,  142. 
Malt   extracts,   ground,   330,  779  ;   HofTs, 

143;    Kepler's,   143;    Loeflund's,   143; 

Trommer's,  143. 
Malt  liquors,  219,  287  ;  gastric  digestion 

and,  211. 
Malted  milk,  81,  132. 
Maltose,  116,  142,  330. 
Mammoth,  frozen,  255. 


794 


INDEX; 


Mania,  587. 
Manioc,  140. 

Mannite,  117  ;  for  diabetics,  657. 
Marasmus,  540  ;  cod-liver  oil  in,  185 ;  in- 
unctions in,  174. 
Maritime  people,  diet  of,  296. 
Marrow,  vegetable,  154;  bone,  177. 
Mash,  sour,  230  ;  sweet,  230. 
Massage,   516 ;    in   chronic    constipation, 

551. 

Mate,  201. 

Matzoon,  73. 

Meal,  137;  banana,  164;  corn,  137;  In-- 
dian,  137  ;  peanut,  172. 

Meals  in  relation  to  sleep,  314. 

Meningitis,  cerebro-spinal,  418. 

Measles,  412.  , 

Meat,  biscuits,  773  ;  composition,  93,  105  ; 
consumption,  92  ;  diet,  93  ;  digestibility, 
27,  95  ;  dried,  250  ;  extract,  770  ;  extract, 
composition  of,  105  ;  fluid  preparations, 
100 ;  frozen,  255  ;  gout  and,  626  ;  hot 
water  and,  612  ;  infection,  361 ;  juice, 
fresh,  100  ;  lozenges,  99 ;  obesity  and, 
612  ;  pancreatinised,  in  enemata,  380 ; 
poisoning,  351  ;  preservation,  260  ;  pu- 
rees, 102  ;  quantity  eaten,  93  ;  rare,  245  ; 
raw,  94,  325,  772  ;  salt,  242  ;  school  chil- 
dren and,  744  ;  scraped,  97  ;  short-fibred, 
105  ;  solid  preparations,  772 ;  soups, 
248  ;  sterilised,  256  ;  tubercular  infec- 
tion, 361  ;  tuberculosis  and,  431  ;  un- 
derdone, 245,  256 ;  Valentine's  juice, 
103 ;  young  children  and,  737. 

Medicines  and  food,  383,  385. 

Meigs's  milk  mixture,  77. 

Melancholia,  587. 

Melons,  160,  169. 

Membranous  enteritis,  541. 

Mental  emotion  and  digestion,  316. 

M^teil,  136. 

Micro-organisms  in  food,  360, 

Migraine,  573. 

Milk,  41  ;  abnormal  digestion  of,  61  ;  ab- 
sorbent power  of,  57  ;  absorption,  43  ; 
acid  with,  67 ;  acute  infection,  535 ; 
adaptation  for  the  sick,  62  ;  adulteration 
of,  51;  alcohol  with,  65,  66;  analyses, 
44,  50,  51  ;  artificial  human,  723  ;  artifi- 
cially thickened,  53  ;  ass's,  49  ;  bacteria 
in.  55.  56,  75  ;  best  form  for  modifying, 
80  ;  boiled,  64  ;  bottles,  76  ;  Bright's  dis- 
ease and,  471 ;  care  of,  723  ;  chemical 


composition,  44 ;  cholera  infection  by, 
361  ;  chronic  gastric  catarrh  and,  506 ; 
cinnamon  and,  773  ;  colour,  49  ;  coloured 
artificially,  52  ;  composition,  44  ;  con- 
densed, 81  ;  condensed  formula,  82 ; 
constipation  and,  43  ;  cure,  44,  694  ;  de- 
rivatives, 81  ;  diabetes  and,  659;  diet, 
42  ;  diet  in  hospitals,  747  ;  digestion,  60  ; 
dilution,  65  ;  diphtheria  germs  in,  363  ; 
disease  germs  in,  54,  55  ;  dispensary,  77  ; 
diuretic  action,  58  ;  dosage,  62,  727, 
728  ;  dried,  250  ;  drugs  in  human,  48, 
718  ;  enemata,  59,  381  ;  estimation  of  al- 
buminoids, 51  ;  estimation  of  fat,  50  ;  es- 
timation of  lactose,  51  ;  exclusive  diet  of, 
42  ;  faeces,  43,  62  ;  fat,  45,  50  ;  fever  and, 
389  ;  foods,  80,  81  ;  fungi  in,  56  ;  gelatin 
and,  67  ;  globules,  45  ;  goat's,  48,  49  ; 
gout  and,  625  ;  gruel,  69  ;  human,  49  ; 
human,  analyses,  46  ;  humanised,  77 ;  hy- 
podermic injections,  60  ;  impurities,  51  ; 
infection,  360 ;  inspection,  52 ;  intra- 
venous injection,  60  ;  inunction,  60 ; 
laboratories,  78  ;  lead  poisoning  and, 
59 ;  Lebert's  cure,  437  ;  legal  standard, 
52;  malt  and,  63;  malted,— &*,  132; 
mare's,  49,  70 ;  Meigs's  mixture,  77 ; 
methods  of  altering  the  taste  of,  63  ; 
methods  of  improving  the  digestibility 
of,  64  ;  modified,  78  ;  pancreatinised,  68  ; 
Pasteurised,  75  ;  peptonised,  67  ;  poi- 
soning, 353  ;  porridge,  779  ;  prediges- 
tion  of,  67,  75  ;  preparations,  67,  773  ; 
prescriptions,  78,  79  ;  preservatives,  53  ;^ 
prophylaxis  against  infection  by,  57 ; 
punch,  63  ;  quantity  required,  43  ;  reac- 
tion, 49  ;  residue,  43  ;  rum  and,  774  ; 
rum  and  isinglass,  780 ;  scalding,  62  ; 
sherry  and,  774  ;  skimmed,  64  ;  solids, 
45,  49,  62  ;  sour,  for  carcinoma,  527  ; 
specific  gravity,  50 ;  starchy  foods  with, 
66  ;  steiilisation,  63,  73  ;  strippings,  46; 
substitutes  for,  400,  723  ;  taste,  49,  62 ; 
tubercular  infection  by,  360,  437  ;  ty- 
phoid fever  and,  378  ;  typhoid  infec- 
tion by,  361 ;  uses  of,  58  ;  varieties,  46; 
vehicle  of  medicines,  59  ;  watered,  52  ; 
diet  in  Bright's  disease,  471. 

Millet,  135. 

Minced  meat,  248. 

Mineral-water  cachexia,  189. 

Mineral  waters,  188. 

Mint,  153,  237. 


INDEX. 


795 


Mixed  diet,  26  ;  feeding,  724. 

Molasses,  116. 

Moleschott,  daily  quantity  of  food  re- 
quired, 269. 

Monotony  of  diet,  212,  305. 

Morel,  170. 

Moselle,  226. 

Mosquera's  beef  jelly,  98  ;  beef  meal,  98. 

Moss,  Iceland,  171. 

Moss  on  meat  composition,  94  ;  sugar  in 
fruits,  table  of,  157. 

Motor  power  of  stomach,  494. 

Mouth,  care  of,  373  ;  care  of  infants',  731  ; 
in  typhoid  fever,  405. 

Mucidin,  121, 

Mucin,  330. 

Mucilage  of  rice,  767. 

Mucous  disease,  541. 

Mulberries,  168. 

Mulled  wine,  769. 

Multiple  neuritis  caused  by  tea,  195, 

Mumps,  412. 

Munich  school,  table  of  food  necessary 
for  different  ages,  283. 

Murchison  on  biliousness,  557. 

Musa  sapientum,  163. 

Muscarin,  171. 

Muscular  exertion  and  food,  313  ;  labour 
and  animal  food,  26. 

Mush,  137. 

Mushrooms,  170. 

Muskmelon,  169. 

Mussels,  112,  113. 

Must  of  wines,  224. 

Mustard,  233,  234. 

Mutton,  105  ;  broth,  771  ;  fat,  177. 

Mytilotoxine,  354. 


Playfair's  diet,  ^80 ;  Weir  Mitchell's 
diet,  581 ;  Wood's  diet,  581. 

New  York  Hospital  dietary,  750. 

New  York  Infirmary  dietary,  758. 

New  York  State  Hospital  dietary,  759. 

New  York  State  Reformator)'  diet,  690. 

New  Zealander's  diet,  296. 

Nitrogen,  i,  2  ;  consumption  of, /^r  Am, 
16  ;  percentage  of,  in  proteid  food,  16  ; 
potential  energy,  18 ;  quantity  elimi- 
nated, 13  ;  quantity  in  different  foods,  3. 

Northeastern  Hospital  for  Children,  diet- 
ary of,  763. 

Nursing  mother,  diet  of  a,  717  ;  bottles,  76. 

Nutmeg,  236. 

Nutrient  enemata,  375  ;  aids  to  retention, 
378  ;  composition  of,  380 ;  methods  of 
injection,  377  ;  number  of,  37S  ;  opium 

in,  379- 

Nutrients,  weights  of,  in  standard  diet- 
aries, 12 ;  in  dietaries  of  different  peo- 
ple, 22. 

Nutrition,  22 ;  processes  involved,  I  ; 
percentage  of,  in  various  foods,  21. 

Nutritive  beverages,  767. 

Nuts,  171,  179  ;  betel,  261  ;  diabetes  and, 
651  ;  kola,  205,  261  ;  oil  of,  179. 


National  dietary,  296. 

Naunyn's  diet  for  diabetes,  661. 

Navy  dietary,  680  ;  rations,  686. 

Nephritis,  acute,  464  ;  dietetic  treatment, 
464 ;  in  children,  466. 

Nervous  system  and  digestion,  307  ;  dia- 
betes and,  638  ;  diet  in  diseases  of  the, 
569. 

Nestle's  food,  81. 

Neuralgia,  569;  alcohol  in,  215;  causa- 
tion, 569  ;  dietetic  treatment,  569. 

Neujasthenia,  217,  574  ;  Bilfinger's  diet, 
581;  causation,  574;  dietetic  treat- 
ment, 568  ;  general  treatment,  575  ; 
Keating's  diet,  581  ;  Leyden's  diet,  580  ; 


Oatmeal,  analysis  of,   140  ;  beef  tea  and, 
772  ;  cooking  of,  139  ;  gruel,  777. 

Oats,  composition,  139. 
^^besity,  599  ;  Banting  system,  603  ;  Bou- 
chard system,  613  ;  Chambers  system, 
613  ;  dietaries  for,  605  ;  dietetic  treat- 
ment, 601  ;  Dujardin-Beaumetz  system, 
612 ;  Ebstein  system,  604  ;  exercise 
for,  607  ;  fruit  diet  in,  160 ;  meat  and 
hot  water  for,  612  ;  Oertel  system,  605  ; 
Schleicher's  system,  610;  Schwenin- 
ger system,  609 ;  See  system,  610 ; 
water  in,  35  ;  Weir-Mitchell  system, 
6to  ;  Yeo  system,  611. 

Occupation  and  diet,  707. 

Oertel  on  functional  albuminuria,  468 ; 
on  obesity,  605. 

Oesophagus,  carcinoma  of,  484 ;  stricture 
of,  484. 

Oil,  almond,  179;  cocoanut,  179:  cod- 
liver,  180;  cotton-seed,  178;  dietetic 
uses  of,  179 ;  for  corrosive  poisoning, 
175  ;  fusel,  229,  231  ;  Java  almond,  179; 
linseed,  179;  olive,  178;  peanut,  179; 
theobroma,  179  ;  tuberculosis  and,  433. 


796 


INDEX. 


Oils,  172;  vegetable,  178. 

Okra,  153. 

Old  age,  dietetic  treatment  in,  286  ;  food 
in,  283. 

Old  Tom  gin,  230. 

Oleochyle,  183. 

Oleomargarine,  176. 

Olive-oil  inunction,  174. 

Olives,  167. 

Omelets,  92. 

Onions,  154. 

Operations,  diet  after,  676. 

Opium  and  fasting,  261  ;  in  enemata,  379. 

Oppolzer,  on  gastric  carcinoma,  527. 

Orange  juice,  162  ;  marmalade,  162  ;  wa- 
ter ice,  162. 

Orangeade,  162. 

Oranges,  162. 

Orvieto  wine,  226. 

Osteomalacia,  672. 

Ovariotomy,  677. 

Overdrinking,  342,  343. 

Overeating,  342  ;  and  diabetes,  633. 

Overfeeding,  719;  in  hospitals,  750. 

Oxaluria,  475. 

Oxygen,  i,  2,  7  ;  death  from  lack  of,  8  ; 
in  food  per  diem,  13  ;  quantity  elimi- 
nated, 13. 

Oyster  plant,  150. 

Oysters,  112;  poisoning  from,  354;  ty- 
phoid infection  and,  362. 

Palpitation,  456. 

Pampas,  diet  of,  297. 

Panada,  780. 

Pancreas,  and  meat  enema,  773. 

Pancreatic,  disease,  568 ;  extract,  143, 
332  ;  juice,  327,  328  ;  solution,  68. 

Pancreatin,  332. 

Pancreatinised  milk  gruel,  69. 

Panopeptone,  104. 

Papain,  334. 

Papoid,  334. 

Paraguay  tea,  201. 

Paralysis,  post-diphtheritic,  418. 

Parasites  in  food,  344. 

Parke's  table  for  war  ration,  685. 

Parkes,  daily  food  required,  269  ;  on  ba- 
nana flour,  165. 

Parotiditis,  412. 

Parsley,  153. 

Parsnips,  150. 

Partridge,  107. 


Pastry,  129. 

Pates,  truffles  in,  170. 

Pavy  on  diabetes,  637,  638. 

Peaches,  163. 

Pea  meal,  146  ;  sausage,  146  ;  soup, 

Peanuts,  172. 

Pearl  barley,  138  ;  sago,  141. 

Pears,  163. 

Peary  expedition,  diet  of,  271. 

Peas,  145. 

Pecan  nuts,  172. 

Pectin  in  fruits,  157. 

Pellegra,  355. 

Pemmican,  178. 

Penzoldt's  vegetable  albumin,  147. 

Pepper,  234 ;  black,  235  ;  Cayenne, 
red,  235  ;  white,  235. 

Peppermint,  232. 

Peppers,  233  ;  green,  153. 

Pepperwort,  261. 

Pepsin,  321,  331  ;  test  for,  494, 

Peptone,  104. 

Peptones,  321,   325,   333  ;  beef,   104 
cess  of,  322. 

Peptonising  powders,  68,  333. 

Peristalsis,  31,  322. 

Peritonitis,  acute,  556  ;  chronic,  557. 

Pernicious  anremia,  463. 

Pertussis,  413. 

Pestilence  and  famine,  281. 

Petit  pois,  146. 

Phosphate  of  lime,  39,  40. 

Phosphorus,  40. 

Phthisis,  cures  for,  440. 

Pickles,  233,  237. 

Pieplant,  154. 

Pigeon,  107. 

Pigments  in  food,  357. 

Pilot  crackers,  125. 

Pineapples,  163. 

Piper  nigrum,  235. 

Plantago  musa,  163. 

Playfair's  diet  for  neurasthenia,  580  ; 
for  puerperal  women,  715. 

Pleurisy,  448. 

Plums,  167. 

Pneumonia,  445. 

Poisoning  by  alcohol,  364  ;  carbonic 
from  wine  making,   223  ;   cheese, 
cream,    353  ;     fish,    353  ;    fruits, 
fungi,  171  ;  game,  351  ;  grain,  364 
cream,    353;.   lead,    360;    meat, 
milk,  353  ;  shellfish,  353  ;  tin,  360. 


146. 


233; 


diet 


acid, 
353; 
159; 
;  ice 

351 ; 


•*3^ 


INDEX. 


797 


Poland  water,  i8g. 

Polenta,  137. 

Poluboskos,  129. 

Polysarcia,  599. 

Pomelo,  161. 

Pomegranates,  163. 

Pork  ribs,  106. 

Porridge,  banana,  165. 

Porter,  221,  232. 

Port  wine,  225,  226,  232. 

Posset,  768. 

Pot-au-feu,  102. 

Potassium,  40  ;  caseinate,  46. 

Potato  composition,  148  ;  starch,  148. 

Potatoes,  147  ;  baked,  149  ;  sweet,  149. 

Potus  imperialis,  768. 

Powder,  baking,  123  ;  beef,  98. 

Prairie  chicken,  107. 

Predigestion   of  proteids,   331  ;    starches, 

330. 
Pregnancy,  vomiting  of,  520  ;  diet  and,  713. 
Premature  infants,  732. 
Presbyterian  Hospital  dietary,  751. 
Preservative  substances,  259. 
Prison  starvation  diet,  280  ;  diet,  688. 
Professional  men,  diet  of,  301,  708. 
Proof  whisky,  230. 

Proteids,  325  ;  as  force  producers,  16 ;  as 
tissue  formers,   16 ;   digestion  in   stom- 
ach,  325  ;    in  intestine,  327  ;  prediges- 
tion of,  331  ;  vegetable,  144. 
Protein,  percentage  of,  in  foods,  il. 
Proteoses,  325. 

Proto-albumose,  325. 

Prunelles,  167.  • 

Prunes,  167. 

Pruritus,  598. 

Prussian   army   hospital  diet,  764 ;  army 
rations,  685. 

Pseudo  -  membranous      gastro  -  enteritis, 
chronic,  541. 

Psoriasis,  598. 

Ptomaines  in  food,  350. 

Ptyalin,  317. 

Puddings,  129. 

Puerperal  woman,  diet  of,  714. 

Pugilist  diet,  707. 

Pulque,  186. 

Pumpkins,  154. 

Purdy,  table  for  infant  feeding,  727. 

Puree,   147,  390 ;  bean,  147  ;   mtat,  io2  ; 
vegetable,  145. 

Purges,  alkaline,  188,  190 ;  saline,  191. 


Purpura  haemorrhagica,  671. 
Pyaemia,  126. 
Pyelitis,  475. 
Pyrosis,  326. 

Quantity  of  food  of  Eskimos,  295. 
Quantity  of  food  required,  261  ;  for  young 

children,  734. 
Quinces,  163. 
Quinsy,  482. 

Rabies,  428. 

Race  and  diet,  291. 

Rachford,  theory  of  fat  digestion,  328. 

Radishes,  1 5 1. 

Raisin  wine,  229. 

Raisins,  167. 

Raspberries,  160,  163. 

Ration,  estimated  life,  13;  garrison,  per- 
centage composition  of,  11  ;  ideal,  with 
solid  food,  14 ;  low  in  proteid,  265 ; 
rich  iQ  proteid,  265  ;  war,  685  ;  work,  13. 

Rations,  navy,  686 ;  United  States  field, 
682;  United  States  garrison,  680;  Unit- 
ed States  travel,  683. 

Revalenta  arabica,  140,  447. 

Raw  meat,  325,  772 ;  sandwiches,  773. 

Receipts  for  invalid  food,  767. 

Rectal  feeding,  375  ;  methods  of,  377. 

Rectum,  alcohol  absorption  from,  312  ; 
care  of,  379. 

Red  wine,  223. 

Reformatory  diet,  690. 

Refrigerant  beverages,  768. 

Refrigeration,  256. 

Religious  fasting,  276,  277. 

Rennet,  46,  61. 

Rennin,  60,  61,  494. 

Rest  and  sleep  and  digestion,  313  ;  cure, 
578. 

Restorative  beef  essence,  771. 

Rhachitis,  664 ;  causation,  664  ;  prophy- 
laxis, 665  ;  dietetic  treatment,  665. 

Rheumatism,  aids  to  dietetic  treatment, 
667  ;  acute,  616  ;  chronic,  618. 

Rheua.atcid  arthritis,  618. 

Rhine  wines,  226,  232. 

Rhone  wines,  228. 

Rhubarb.  154. 

Rice,  apple  and,  778  ;  l)oilcd,  778  ;  cream, 
778;  digestibility  of,  138;  flour  in 
bread,  124;  gruel,  778;  milk,  778; 
»oup,  776  ;  water,  767. 


798 


[iJIp^T 


Richards,  Mrs.  E.  H.,  convalescent,  ra- 
tion, 265  ;  food  composition,  table  of, 
282  ;  food  consumption  by  young  wom- 
en students,  tt^bHof,  263  ;  ideal  ration 
of  liquid  food,  205  ; 


ideal  ration  of  solid 


Leube's  test  dinner,  490. 

?g,  243- 

s,  effect  of  tea  and  coffee  on  gas- 
digestion,  193,  194 ;  hydrochloric 
digestion,  table  of,  320  ;  influence 
wines  on  digestion,  229  ;  malt  liquors 
and  gastric  digestion,  211. 
Roe,  III. 
Rolls,  121. 

Roosevelt  Hospital  dietary,  757. 
Root  beer,  188. 
Roquefort,  87. 
Rosacea,  597. 
Rotch's  method  of  modifying   milk,    79 ; 

table  for  infant  feeding,  727. 
Round  worms,  145,  304,  345. 
Rubeola,  412. 
Rudisch's  beef  peptone,  99. 
Rules  for  feeding  young  children,  734. 
Rum,  229,  230;  and  milk,  774. 
Rye,  129,  136;    bread,  125,  129;    whisky, 
230. 

Saccharin,  117  ;  for  diabetes,  657. 

Saccharomyces  cerevisiae,  205  ;  in  beer, 
220. 

Saccharose,  114. 

Sago,  141. 

Sake,  230. 

Salep,  140. 

Salicylic  acid  in  food,  260,  358. 

Saline  purges,  191  ;  waters  in  gout,  630. 

Saliva,  317. 

Salivary  digestion,  317. 

Salmon,  no. 

Salsify,  150. 

Salt,  37  ;  celery,  253  ;  craving  for,  40  ;  de- 
privation of,  38  ;  excess  of,  38,  40  ;  habit, 
38  ;  meat,  242  ;  starvation,  39  ;  uses  in 
food,  38  ;  varieties,  37. 

Salts,  deposition  of,  40  ;  in  calculi,  38  ; 
gastric  juice  and,  493  ;  percentage  of,  in 
foods,  II. 

Salting,  254. 

Samp,  137. 

Sarco-peptones,  99. 

y 


Sarsaparilla,  188. 

Sauces,  237. 

Sauerkraut,  152. 

Savory  and  Moore's  Food,  131,  132. 

Scarlatina,  411  ;  infection  by  milk,  363. 

Schiedam,  230. 

Schleicher's  diet  for  obesity,  610. 

Schlossberger's  mea^  composition,  table 
of,  93. 

School  children's  diet,  740. 

Schroth's  dry  diet,  449. 

Schweninger  system,  6og. 

Sclerosis,  arterial,  456. 

Scotch  beef  broth,  772  ;  groats,  139  ;  whis- 
ky, 230. 

Scrofula,  662  ;  dietetic  treatment  of,  663. 

Scurvy,  raw  meat  in,  94  ;  causation  of,  668. 

Seakale,  152. 

Seasickness,  519  ;  lemons^in,  161. 

Secretion,  of  gastric  juice,  319  ;  of  saliva, 

317- 

See's  treatment  of  dyspepsia,  499 ;  of 
obesity,  610. 

Seegen's  almond  cakes,  656. 

Semolino,  134. 

Senile  heart,  diet  for,  453, 

Sepsis,  678. 

Septicaemia,  426. 

Shaddock,  161. 

Shallots,  154. 

Shellfish  poisoning,  353. 

Sherry,  225,  226,  232  ;  and  milk,  774. 

Ship  biscuits,  134. 

Shore  dinners,  112. 

Shrimps,  112. 

Siberian  fungus,  261. 

Siever's  test  for  motor  power  of  stomach, 
494. 

Sirup,  113  ;  maple,  114. 

Skin,  absorption  of  water  by,  36  ;  diseases, 
diet  in,  591  ;  diseases  dietetic  aetiology, 
591  ;  in  diabetes,  642. 

Sleep,  314  ;  disordered,  582  ;  feeding  and, 
373,  739  ;  food  of  the  Eskimos  and,  294  ; 
food  in  typhoid  fever  and,  402  ;  in  rela- 
tion to  meals,  314  ;  rest,  digestion,  and, 

313- 
Smallpox,  410. 
Smoked  beef,  254. 
Smoking,  254. 
Snipe,  107. 
Sodium,  2. 
Sodium  carbonate  in  milk,  260  ;  in  tea,  195. 


«• 


^     ^tf  INDEX. 

Sodium   chloride,  39  ;    as  a  preservative, 

40 ;  waters,  190. 
Soft-shell  crabs,  112. 
Solid  meat  preparations,  97. 
Solis-Cohen  diet  for  forced  feeding,  439. 
Somatose,  100. 
Sophistication  of  food, -356. 
Sorghum,  116,  135. 
Sorrel,  15^ 

390,   772 
in  gout 


commission, 
625  ;  ox-tail. 


Soup,   248,   301, 

107  ;  fruit,   160 

109  ;  rice,  776. 
Soused  fish,  260. 

South  American  beef  extract,  99. 
South  Sea  Islander,  diet  of,  297. 
Soya  bread,  135,  656. 
Soyer,  food  eaten  during  lifetime,  table  of, 

274. 
Spaghetti,  135. 

Special  diets  in  hospitals,  748. 
Spices,  233,  236  ;  properties  of,  233  ;  uses 

of,  236. 
Spiegelberg  on  diet  for  puerperal  women, 

715- 

Spinach,  152. 

Spirits,  230,  232. 

Spratling,  tea  causing  multiple  neuritis, 
195. 

Squash,  154. 

Standard  daily  diet,  264, 265  ;  dietaries,  12. 

Starch,  118. 

Starches  in  intestine,  327 ;  predigestion 
of,  330. 

Starchy  foods  in  general,  118;  for  chil- 
dren, 141. 

Starr,  dietaries  for  young  children,  735  ; 
on  infant  feeding,  728  ;  table  of  infant 
feeding,  72S  ;  weaning  mixture,  726. 

Starvation,  274  ;  during  siege  of  Paris, 
280  ;  diet  in  prison,  280 ;  diet  in  U.  S. 
military  prison,  280 ;  fat  loss  in,  172  ; 
insomnia  and,  315  ;  of  De  Long  expe- 
dition, 279  ;  of  Greely  expedition,  280  ; 
symptoms  of,  277  ;  treatment  of,  281. 

Stature  and  food,  289,  294. 

Steaks,  245. 

Steaming,  247. 

Steam  sterilisers,  73. 

Steapsin,  328. 

Stearin,  176. 

Sterilisation,  256. 

Stewart,  formulae  for  cod-liver  oil  emul- 
sions, 182. 
53 


799 


Stewart, .  Granger,    on    functional    allu- 

minuria,  469  ;  diabetic  bread,  654. 
Stewing,  247. 
Stews,  243. 


Stimulants.^P  ;  action  of,  li 


uses,  187. 


xnRl 


fat^L' 
,    73I9 


Stimulating  foods,  it 

Stokes's  Cognac  mixr 

Stomach,  acute  catarrh 
489 ;  chronic  catarrh, 
525  ;    dilatation,   511 
contents,  489  ;  faradisa^ 
typhoid  fever,  405 ;  of  i? 
test  for  absorbent  power, 
motor  power,  495  ;  ulcer,  522. 

Stomatitis,  catarrhal,  482. 

Stone  in  the  bladder,  476  ;  in  the  ]|:idney, 
476.  .  .  "^  ^5  » 

Stools,  diarrhoeal,  bacteria  in,  532 
532 ;    casein    in,     532 ;    infants', 
meat  fibre  in,  533  ;  starch  in,  533. 

Stout,  221. 

Stracchino,  88. 

Strawberries,  l6o. 

Stutzer,  analysis  of  cocoa,  202. 

Succi,  voluntary  fast  of,  276. 

Succulent  tubers,  150. 

Sucrose,  114.  ^,^^ 

Suet,  176. 

Sugar,  beet,  115,  150;  cane,  114;  in  in- 
testine, 327  ;  composition  in  body,  1 14  ; 
from  rags,  10;  grape,  114,  116;  gout 
and,  626;  in  fruit,  114,  157;  maple, 
114;  milk,  116;  refining,  115;  source, 
113;  substitutes  for,  in  diabetics,  657  ; 
sugars,  113  ;  the  urine  and,  114. 

Sulphates,  41. 

Sulphur,  41  ;  waters,  19a 

Summer  diarrhoea,  534. 

Superalimentation,  438. 

Supper  hour,  300. 

Suppositories  of  food,  382. 

Suralimentation,  438. 

Surgical  inflammations,  678 ;  operations, 
diet  after,  patients'  injuries,  676. 

Syntonin,  325. 

Syphilis  of  liver,  565. 

Sweetbread,  107. 

Sweet  potatoes,  149. 

Sweets  for  children,  745. 

Swiss  milk,  82  ;  Alpine  milk,  82. 

Tabasco,  233,  237. 
Table  waters,  189. 


8oo 


INDEX. 


Tjenia,  345. 

Tallow,  176. 

Tamarind  whey,  769. 

Tamarinds,  163. 

Tanner,  voluntary  fast  of,  276. 

Tannin,  191. 

Tapeworms,  145,  345  ;  pomegranate  for, 
163. 

Tapioca,  140. 

Tarragon,  153. 

Taste  and  food,  303. 

Tea,  192,  260  ;  adulteration  of,  196 ;  anal- 
ysis of,  192  ;  beef,  769  ;  coffee  com- 
pared with,  201  ;  flaxseed,  768 ;  good 
eff"ects  of,  193  ;  gout  and,  628  ;  habit, 
199  ;  ill  effects  of,  105  ;  influence  of,  on 
gastric  digestion,  194  ;  infusion,  193  ;  lin- 
seed, 768  ;  method  of  preparation  of,  192  ; 
Paraguay,  201  ;  physiological  action  of, 
193  ;  properties  of,  193  ;  quantity  "con- 
sumed, 196  ;  therapeutic  action  of,  193. 

Teething  and  food,  739. 

Temperature  and  digestion,  308. 

Tests  for  absorptive  power  of  stomach, 
495  ;  for  motor  power  of  stomach,  494  ; 
meals,  490. 

ests  for  acid  salts,  493  ;  for  free  hydro- 
chloric acid,  491,  492  ;  for  stomach  con- 
tents, 325. 

Tetanus,  427. 

Theobroma  cacao,  201. 

Theobromine,  202. 

Therapeutic  use  of  liquors,  231. 

Thirst,  36,  298  ;  diabetes  and,  640 ;  ice 
for,  37 ;  lemons  for,  36,  161  ;  rectal 
feeding  and,  376  ;  relief  of,  36. 

Thompson,  Sir  H.,  on  biliousness,  557; 
on  food  in  old  age,  286 ;  on  obesity, 
599  ;  on  overeating,  262. 

Thyroid  gland,  108. 

Tin  poisoning,  358. 

Toast,  dry,  126. 

Tobacco,  260 ;  food  and,  337  ;  in  chronic 
constipation,  552. 

Tokay,  225,  226. 

Tomato  catsup,  237. 

Tomatoes,  153. 

Tongue,  105. 

Tonsilitis,  482. 

Torrefied  bread,  654. 

Torula,  121. 

Tous-les-moisy  140. 

Tracheotomy,  feeding  in,  417. 


Trained  food  purveyors,  386. 

Training,  athletic,  703. 

Travel  ration  in  army,  683  ;  and  diet,  712. 

Treacle,  116. 

Treatment,  dietetic,  of  typhoid  fever,  398. 

Trichiniasis,  346  ;  diagnosis  of,  349  ;  pro- 
phylaxis for,  348  ;  symptoms  of,  348  ; 
treatment  of,  350. 

Tripe,  108. 

Trommer's  Diastatic  Malt  Extract,  143. 

Truffles    170. 

Tubercular  laryngitis,  441. 

Tuberculosis,  aids  to  dietetic  treatment, 
440  ;  alcohol  in,  434  ;  causation,  428  ; 
cod-liver  oil,  433 ;  diet  in  advanced 
cases,  436 ;  diet  in  mild  cases,  434 ; 
eggs  in,  432 ;  fats  and  oils,  433  ;  gen- 
eral consideration  of  dietetic  treatment, 
429  ;  meats  in,  431  ;  milk  diet  in,  437. 

Tubers,  147. 

Tufnell's  diet  for  aneurism,  457. 

Turkey,  107. 

Turkish  figs,  169. 

Turnip  tops,  152. 

Turnips,  150. 

Typhoid  fever,  397  ;  alcohol  in,  403  ;  con- 
valescent diet,  406  ;  dietetic  treatment, 
398  ;  feeding  atypical  cases,  408 ;  in 
children,  409  ;  milk  infection  and,  361  ; 
oyster  infection  and,  362 ;  pathological 
physiology,  397. 

I'yphus  fever,  410. 

Tyrotoxicon,  353. 

Tyson's  diabetic  diet,  659. 

United  States  army  diet,  680  ;  army  hos- 
pital dietary,  763  ;  army  prison  diet, 
688  ;  navy  diet,  686  ;  navy  ration,  687. 

Ulcer  of  stomach,  522. 

Urea  and  animal  food,  25. 

Uric-acid  diathesis,  478. 

Urinary  system,  diet   in  diseases  of  the, 

463- 

Urine,  alkalinity  from  fruits,  158 ;  dia- 
betic, 641  ;  food  and,  336  ;  sugar  in, 
114;  modifications  caused  by  food,  463. 

Urticaria,  592. 

Utica  State  Hospital  for  Insane,  dietary 
of,  760. 

Valentine's  meat  juice,  103. 

Vanilla,  236. 

Van  Noorden's  treatment  of  anaemia,  461. 


I 


INDEX. 


80 1 


Varieties  of  cooking,  239. 

Variety  in  diet,  305  ;  in  army  diet,  307  ; 
in  children's  diet,  741. 

Variola,  410. 

V^arious  waters,  igi. 

baseline  in  butter,  358. 

V^aughan  on  ptomaines,  353. 

V^eal,  105  ;  broth,  771. 

V^egetable  and  animal  foods  compared, 
22  ;  acids,  41  ;  albumin,  147,  325  ;  case- 
in, 325  ;  diet,  144 ;  extract  for  flavour- 
ing, 102  ;  foods  and  bile,  327  ;  marrow, 
154;  proteids,  144;  purees,  145. 

V^egetables,  antiscorbutic,  145  ;  classifica- 
tion of,  144 ;  composition  of,  151  ;  con- 
stipation and,  548;  diabetes  and,  651, 
653  ;  dried,  250  ;  gout  and,  626  ;  green, 
151  ;  laxative,  145  ;  raw,  249  ;  stimulant, 
145  ;  table  of  composition  of,  155  ;  in 
diabetes,  651,  653  ;  young  children  and, 

737- 

Vegetarians,  297. 

Venison,  106. 

Vermicelli,  135. 

Vermuth,  232. 

Vertigo,  582. 

Vichy,  189,  190. 

Vin  d'Asti,  226. 

Vinegar,  233,  234,  236  ;  excess  of,  237  ; 
white,  236. 

Fins  du  luxe,  225. 

Visceral  neuralgias,  571. 

Voit  on  functional  albuminuria,  469  ;  on 
obesity,  601. 

Voluntary  fasting,  275. 

Vomiting.  518;  dietetic  treatment,  519; 
pathological  physiology,  518;  pregnan- 
cy, 521. 

Von  Bibra's  table  of  meat  composition,  93. 

Walnuts,  English,  171. 

War  ration,  685. 

Waste,  elimination  of,  335,  336. 

Water,  30  ;  a  force  producer,  15  ;  amount 
used,  30;  as  a  food,  15;  barley,  767 ; 
boiled.  33;  constipation  and,  550; 
death  from  lack  of,  8  ;  deprivation  of, 
35  ;  diabetes  and,  658 ;  dietetic  uses, 
34 ;  distilled,  33  ;  elimination  of,  30 ; 
emetic  use  of,  31  ;  excess,  34  ;  filtered, 
33  ;  filtration,  32  ;  gases  in,  33  ;  germs 
in,  31-33  ;  gout  and,  628  ;  hard,  32  ;  hot, 
for  obesity,  612  ;  hot,  for  thirst,  37  ;  in 


blood,  34 ;  in  fevers,  392 ;  in  food, 
34  :  in  solid  food,  15  ;  Johannis,  189  ; 
Kronenquelle,  190  ;  lime,  home-made, 
775  ;  lithia,  190 ;  percentage  of,  in 
foods,  11;  Poland,  189;  purity,  31; 
quantity,  30 ;  quantity  eliminated,  13  ; 
quantity  required  per  diem,  270;  rain, 
32  ;  rice,  767  ;  river,  33  ;  salts  in,  32 ; 
secretion,  30  ;  soft,  32  ;  spring,  32  ; 
starvation,  35  ;  temperature  of  drinking, 
37  ;  uses,  31 ;  varieties  of  drinking,  32. 

Waters,  carbonic-acid,  189  ;  sodium-chlo- 
ride, 190  ;  sulphur,  190  ;  table,  189  ; 
thermal,  189. 

Watermelons,  169. 

Weaning,  724. 

Webster's  diet  for  forced  feeding,  449. 

Weighing  of  infants,  731. 

Weir  Mitchell's  treatment  for  neurasthe- 
nia, 579  ;  for  obesity,  610. 

Wet  nurse,  diet  of,  717  ;  selection  of,  716. 

Wheat-kernel  structure,  120. 

Wheatena.  133. 

Whey,  88 ;  cream  of  tartar,  768  ;  cure, 
697  ;  tamarind,  769  ;  wine,  768. 

Whisky,  229,  250. 

White  wine,  223. 

Whiting,  III. 

Whooping  cough,  413. 

Wiley  on  canned  foods,  259. 

Williams  on  boiling,  240  ;  on  frying,  247  ; 
on  stewing,  243. 

Wine,  221  ;  bouquet,  221,  222  ;  coca,  225  ; 
composition  of,  221,  223  ;  consumption 
of,  219  ;  elderberry,  169  ;  fermentation 
of,  221,  222  ;  fig,  232  ;  flavour  of,  222  ; 
fruitiness  of,  222  ;  general  properties  of, 
222  ;  mulled,  225,  769  ;  sugar  in,  222  ; 
whey,  768. 

Wines,  acid,  226 ;  in  fevers,  394  ;  influ- 
ence upon  digestion,  229  ;  perfect,  227  ; 
red,  223  ;  Rhine,  226,  232  ;  rough,  229  ; 
sparkling,  226 ;  strong  dry,  224  ;  strong 
sweet,  226  ;  uses  of,  228  ;  varieties  of, 
224 ;  white,  223. 

Woman's  milk,  analysis  of,  47  ;  drugs  in, 
48. 

Woodcock,  107. 

Woodhull  on  army  ration,  685. 

Woodruff',  on  army  rations,  684  ;  on  com- 
position of  military  pea  food,  146 ;  on 
compressed  bread,  251  ;  on  food  con- 
centration,  252  ;    on   variety   in    army 


802 


INDEX. 


diet,  194 ,  use  of  alcohol  in  the  army, 
208  ;  use  of  tea  and  coffee  in  the  army, 
194. 

Wood's  diet  for  neurasthenia,  581. 

Worcestershire  sauce,  237. 

Worit  ration,  13. 

Wort,  220. 


Yale  crew  diet,  705  ;    foolball-team   diet, 

707. 
Yeast  fungus,  121,  205  ;  leaven,  122. 
Yellow  fever,  422  ;  dietetic  treatment,  424. 
Yeo,  composition  of  fruits,  table  of,  157  ; 

diet  for  the  aged,  table  of,  287  ;  system 

for  obesity,  611. 


THE  DISEASES  OF  THE 
STOMACH. 

By    Dr.    C.    A.    EWALD, 

EXTRAORDINAISY    PROFESSOR    OF    MEDICINE    AT    THE    UNIVERSITY    OF    BERLIN. 

Second  American  Edition,  translated  arid  edited,  icith  mimerous  Additions, 
from  the  Third  German  Edition, 

By  MORRIS    MANGES,  A.  M.,  M.  D., 

ASSISTANT    VISITING    PIIVSICIAN    TO    MOTNT    SINAI    HOSPITAL;     LECTURER   ON 
GENERAL    MEDICINE,    NEW     YORK     POLYCLINIC,    ETC. 

This  work  has  been  thoroughly  revised,  rearranged,  largely  rewritten,  and 
brought  up  to  date  from  the  most  recent  literature  on  the  subject. 


8vo,  602  pages.    Sold  by  subscription.    Cloth,  $5.00 ;  sheep,  $6.00. 


"In  giving  the  medical  profession  this  second  revised  translation  of  Prof. 
Ewald's  treatise  on  the  Diseases  of  the  Stomach,  Dr.  Manges  has  placed  the  profes- 
sion under  even  greater  obligations  than  we  owed  for  the  first.  The  first  transla^ 
tion  was  then  an  almost  exhaustive  treatise,  and  now,  with  so  much  new  and 
valuable  data  added,  the  work  is  a  sine  qua  non." — Atlanta  Medical  and  Surgical 
Journal. 

"  This  work  as  it  now  stands  is  the  best  on  the  subject  of  stomach  diseases  in 
the  English  language.  No  physician's  library  is  complete  without  it.  It  is  in 
every  way  well  atlapted  to  the  requirements  of  the  general  practitioner,  although 
complete  enough  to  meet  also  the  requirements  of  the  specialist." — American 
Medico- Surgical  Bulletin. 

"  The  present  American  edition  is  a  peculiarly  valuable  one,  as  the  editor. 
Dr.  Manges,  has  done  his  work  in  a  thoroughly  creditable  manner.  His  numer- 
ous notes,  additions,  and  new  illustrations  have  made  the  book  a  classic  one. 
Under  these  circumstances  it  should  find  a  place  in  the  library  of  every  Amer- 
ican physician,  as  their  clientele  is  composed  of  such  a  large  proportion  of  patients 
suffering  from  gastric  conifilaints  and  more  or  less  improper  medication  which 
most  often  ends  in  failure.  There  is  no  doubt  that  more  properly  directed  efforts 
in  the  proper  direction,  as  outlined  in  Ewald's  book,  would  soon  remove  from 
Americans  the  reputation  of  being  a  nation  of  dyspeptics." — St.  Louis  Medical 
and  Surgical  Journal. 

"  Dr.  Ewald's  book  has  met  with  a  very  cordial  reception  by  the  medical  pro- 
fession. Within  a  short  period  three  editions  have  appeared,  and  translations 
published  in  England.  Spain,  France,  Italy,  and  the  United  States.  To  the 
present  edition  the  author  has  not  only  added  considerable  now  matter,  but  he 
has  also  entirely  rewritten  the  work.  The  arrangement  nf  the  chapters  has  been 
somewhat  changed,  and  many  new  personal  observations  and  therapeutic  experi- 
ences added.  The  desirability  of  surgical  interference  is  carefully  considered,  and 
the  pros  and  cons  given  so  far  as  would  1«  necessary  to  enable  a  physician  to 
determine  whether  the  aid  of  the  surgeon  might  Ije  required.  The  translator  has 
done  his  work  well,  and  has  incorporated  much  new  matter  into  the  text  and 
footnotes." — North  American  Journal  of  Homceopathy. 


D.  APPLETON  AND  COMPANY,  NEW  YORK. 


A  New,  Thoroughly  Revised,  and  Enlarged  Edition  of 

QUAIN'S 
DICTIONARY  OF  MEDICINE. 

BY   VARIOUS   WRITERS. 

Edited  by  Sir  RICHARD   QUAIN,   Bart,  M.  D.,  LL.  D.,  etc., 

Physician  Extraordinary  to  Her  Majesty  the  Queen  ;  Consulting  Physician  to  the  Hospital  for  Diseases 
of  the  Chest,  Brompton,  etc. 

Assisted  by  FREDERICK   THOMAS    ROBERTS,  M.  D.,  B.  Sc, 
Fellow  of  the  Royal  College  of  Physicians,  etc. ; 

And  J.  MITCHELL   BRUCE,  M.A.,  M.  D., 
Fellow  of  the  Royal  College  of  Physicians,  etc. 

With  an  American  Appendix  by  SAMUEL  TREAT  ARMSTRONG,  Ph.D.,  M.  D., 

Visiting  Physician  to  the  Harlem,  Willard  Parker,  and  Riverside  Hospitals,  New  York. 


IN  TWO  VOLUMES.  Sold  only  by  subscription. 


This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are  fully 
discussed  in  alphabetical  order.  The  description  of  each  includes  an  account  of  its  etiology 
and  anatomical  characters ;  its  symptoms,  course,  duration,  and  termination  ;  its  diagnosis, 
prognosis,  and,  lastly,  its  treatment.  General  Pathology  comprehends  articles  on  the  origin, 
characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies,  their  modes  of 
action,  and  on  the  methods  of  their  use.  The  articles  devoted  to  the  subject  of  Hygiene  treat 
of  the  causes  and  prevention  of  disease,  of  the  agencies  and  laws  affecting  public  health,  of 
the  means  of  preserving  the  health  of  the  individual,  of  the  construction  and  management  of 
hospitals,  and  of  the  nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  respective 
headings,  both  in  aggregate  and  in  detail. 

The  American  Appendix  gives  more  definite  information  regarding  American  Mineral 
Springs,  and  adds  one  or  two  articles  on  particularly  American  topics,  besides  introducing 
some  recent  medical  terms  and  a  few  cross-references. 

The  British  Medical  yournal  says  of  the  new  edition  : 

"The  orii^inal  purpose  which  actuated  the  preparation  of  the  original  edition  was,  to 
quote  the  words  of  the  preface  which  the  editor  has  written  for  the  new  edition,  '  a  desire  to 
place  in  the  hands  of  the  practitioner,  the  teacher,  and  the  student  a  means  of  ready  reference 
to  the  accumulated  knowledge  which  we  possessed  of  scientific  and  practical  medicine,  rapid 
as  was  its  progress,  and  difficult  of  access  as  were  its  scattered  records.'  The  scheme  of  the 
work  was  so  comprehensive,  the  selection  of  writers  so  judicious,  that  this  end  was  attained 
more  completely  than  the  /nost  sanguine  expectations  of  the  able  editor  and  his  assistants 
could  have  anticipated.  ...  In  preparing  a  new  edition  the  fact  had  to  be  faced  that  never 
in  the  history  of  medicine  had  progress  be^n  so  rapid  as  in  the  last  twelve  years.  New  facts 
have  been  ascertained,  and  new  ways  of  looking  at  old  facts  have  come  to  be  recognized  as 
true.  .  .  .  The  revision  which  the  work  has  undergone  has  been  of  the  most  thorough  and 
judicious  character.  .  .  .  The  list  of  new  writers  numbers  fifty,  and  among  them  are  to  be 
found  the  names  of  those  who  are  leading  authorities  upon  the  subjects  which  have  been 
committed  to  their  care."  • 


D.  APPLETON   AND   COMPANY,   NEW  YORK. 


A  TREATISE  ON 

THE  DISEASES   OF  THE 

NERVOUS   SYSTEM. 

By  WILLIAM  A.  HAMMOND,  M.D., 

Surgeon-General  U.  S.  Army  (retired  list). 

With  the  Collabobatiox  of  GRAEME  M.  HAMMOND,  M.  D,, 

Professor  of  Diseases  of  the  Mind  and  Xervous  System  in  the  New  York 
Post-Graduate  Medical  School  and  Hospital,  etc. 

With  118  Illustrations. 
NINTH    EDITION,   WITH    CORRECTIONS    AND   ADDITIONS. 


8vo.    932  pages.    Cloth,  $5.00;  sheep,  $6.00. 


"  Dr.  riammond's  treatise  on  the  diseases  of  the  nervous  syst«m  is  a  work  which 
has  been  long  familiar  to  the  profession,  and  has  attained  a  great  reputation  among 
the  standard  books  for  reference.  In  the  preparation  of  the  present  edition  the 
author  has  been  aided  by  his  son,  A  vast  amount  of  clinical  material  is  made  use 
of,  and  the  results  of  experimental  investigation  recorded.  The  book  is  written  in 
a  clear  and  pleasing  style,  and  obscure  conditions  are  dealt  with  in  a  manner  which 
will  prove  of  great  assistance  in  the  study  of  this  most  interesting  class  of  diseases." 
— Canadian  Practitioner, 

"Dr.  Hammond  published  the  first  edition  of  his  'Treatise  on  Diseases  of  the 
Xervous  System '  in  1871.  It  has  therefore  been  before  the  profession  for  twenty 
yeai-s,  and  during  these  years  it  has  continued  to  grow  in  public  favor,  this  being 
the  ninth  edition  that  has  been  issued.  Appreciation  of  this  work  has  not  only 
been  shown  in  this  country,  but  abroad,  as  it  has  been  translated  into  the  French, 
the  Italian,  and  the  Spanish  languages.  The  present  edition  has  been  thoroughly 
revised,  and  several  new  chapters  added.  This  is  a  book  of  such  great  value,  and  is 
referred  to  so  frequently  by  the  medical  press  and  other  medical  works,  that  no 
library  is  complete  without  it." — Alabama  Medical  and  Surgical  Age. 

"  There  are  few  books,  even  upon  those  subjects  which  are  constantly  in  the 
ordinary  physician's  mind,  which  succeed  as  has  that  of  Dr,  Hammond  ;  and  when 
we  recollect  that  when  the  first  edition  of  this  work  appeared,  neurology  in  America 
was  in  its  very  infancy,  the  rapid  exhaustion  of  its  editions  is  the  more  remarkable. 
In  the  ninth  edition  the  writer's  son  has  done  much  toward  keeping  the  work  abreast 
of  the  times,  and,  with  more  confidence  than  ever,  it  can  now  be  regarded  as  one  of 
the  best  and  most  satisfactory  works  on  nervous  diseases,  either  for  the  practitioner 
or  for  the  advanced  student.  The  book  is  beaiitiflp<l  and  its  usefulness  increased  by 
a  larger  number  of  illustrations  than  heretofore— among  the  best  from  a  medical 
point  of  view  being  those  representing  syringo-myelia,  which  have  been  taken  from 
the  studies  of  Van  Oiesen." — Medical  Neirs. 


D.   APPLETON    AND   COMPANY,  NEW   YORK. 


■    A  TREATISE  ON  THE 

PEACTICE  OF  MEDICINE, 

FOR  THE  USE  OF  STUDENTS  AND  PRACTITIONERS. 
By   EGBERTS    BAETHOLOW,    M.  A.,  M.  D.,  LL.  D., 

Late  Professor  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia ;  formerly  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Medical  College  of  Ohio  at  Cincinnati,  etc. 


Seventh  Edition^  revised  and  enlarged.     8vo.     1003  pages. 
Cloth,  $5.00;  sheep,  $6.00. 


"  The  large  number  of  readers  who  are  already  familiar  with  this  work  will  be  glad 
to  learn  that  the  present  edition  has  been  carefully  revised  by  tde  author,  considerably 
enlarged,  and  is  intended  to  include  all  that  has  in  the  most  recent  period  been  added  to 
practical  medicine,  especially  in  its  clinical  horizon.  The  author  felicitates  himself  on 
the  large  sales  obtained  for  the  previous  editions,  and  there  is  no  reason  why  the  present 
one  should  not  continue  to  gain  in  the  opinion  of  many.  What  doubtless  lends  the  vol- 
ume one  of  its  special  attractions  to  these  is  the  authoritative  expressions  which  are  fre- 
quent in  its  pages  on  subjects  where  the  reader  might  be  left  in  uncertainty  elsewhere. 
This  remark  applies  both  to  pathology  and  treatment.  The  fullness  with  which  thera- 
peutics are  taught  stands  in  noteworthy  contrast  to  the  majority  of  treatises  on  practice. 
This,  too,  is  undoubtedly  a  feature  which  will  be  agreeable  to  numerous  purchasers. 
Some  seeming  excess  of  conciseness  in  certain  portions  is  explained  by  the  fact  that  this 
is  but  one  volume  of  a  series  proposed  by  the  author,  which  will  cover  the  whole  domain 
of  special  pathology  and  therapeutics." — Medical  and  Surgical  Reporter. 

"  This  valuable  work  appears  in  its  sixth  edition  considerably  enlarged,  and  improved 
materially  in  many  respects.  The  arrangement  of  the  subjects  appears  to  be  pretty  much 
the  same  as  in  former  editions,  and  the  description  of  diseases  is  also  little  modified. 
Some  new  chapters  have  been  added,  however,  and  new  subjects  introduced,  making  the 
volume  completely  cover  the  entire  domain  of  practice,  without  anything  superfluous. 
Considering  the  immense  scope  of  subjects,  the  directness  of  statement,  and  the  plain, 
terse  manner  of  dealing  with  the  phenomena  of  disease,  this  practical  work  has  no  counter- 
part."— Kansas  City  Medical  Record. 

"  That  six  editions  of  such  a  work  should  be  called  for  in  six  years  is  perhaps  the 
most  flattering  testimonial  that  a  book  can  receive,  and  must  outweigh  every  other  com- 
ment, favorable  or  unfavorable.  In  the  preface  to  this  edition  is  an  announcement  which 
will  be  welcomed  by  all  of  Dr.  Bartholow's  numerous  admirers,  namely,  that  he  has  now 
in  preparation  another  work  on  the  '  Principles  of  Medicine,'  which,  together  with  the 
one  under  review,  and  his  '  Materia  Medica  and  Therapeutics,'  shall  constitute  a  trio  of  vol- 
umes each  containing  matter  complementary  to  the  others.  Certainly  three  such  volumes 
must  constitute  a  monument  which  will  render  the  writer's  fame  almost  undying." — 
Medical  Press  of  Western  New  York. 


D.  APPLETON   AND   COMPANY,  NEW  YORK. 


This  book  !«  oTTr 


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